Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com 212 ORIGINAL ARTICLE The management of sexually transmitted infections by Australian general practitioners V J Johnston, H Britt, Y Pan, A Mindel ............................................................................................................................... Sex Transm Infect 2004;80:212–215. doi: 10.1136/sti.2003.006957 See end of article for authors’ affiliations ....................... Correspondence to: Professor A Mindel, Sexually Transmitted Infections Research Centre (STIRC), University of Sydney, Marian Villa, Westmead Hospital, Westmead, NSW 2145, Australia; adrianm@ icpmr.wsahs.nsw.gov.au Accepted for publication 19 November 2003 ....................... I Objectives: To ascertain how frequently general practitioners (GPs) in Australia encounter sexually transmitted infections (STIs), how STIs are managed in general practice, and the characteristics of GPs who manage STIs. Methods: Data were derived from the Bettering the Evaluation and Care of Health (BEACH) database. BEACH is a cross sectional survey of national GP activity. Approximately 1000 GPs per year each record details of 100 consecutive patient encounters. Details from April 1998 to March 2001 about frequency and pattern of STIs managed and the characteristics of GP managing them were analysed using SAS. Results: 3030 GPs provided data on 303 000 encounters. Only 521 problems managed were STIs. Viral STIs were most frequently managed including genital herpes (0.08 per 100 encounters), genital warts (0.07 per 100 encounters). Gonorrhoea, syphilis, chlamydia, and trichomoniasis were rarely managed. Medication was prescribed at a rate of 56.1 per 100 STI contacts (95% CI 50.4 to 61.7). Antivirals were the most common followed by topical chemotherapeutics. GPs managing STIs were significantly younger and more likely to be female, urban, have fewer years in practice, work fewer sessions a week, work in a larger practice, have graduated in Australia, and hold the FRACGP (all p,0.005) than those who did not. Conclusion: Management of diagnosed STIs forms only a small part of a GP’s workload in Australia. Genital herpes and warts are the most commonly managed conditions. GPs managing STIs are different from those who do not. Strategies to improve diagnosis, management, and screening should be evaluated. n Australia sexual health services are provided by a number of agencies including sexual health clinics, family planning clinics, gynaecologists, infectious disease specialists, Aboriginal Medical Services (AMS), and general practitioners (GPs). GPs are ideally placed to have a major impact on sexually transmitted infection (STI) prevention, diagnosis, and management, with over 80% of Australians attending a GP in any one year.1 However, it is not known how frequently STIs are managed in general practice. Limited general practice surveillance data are available from Australia. A questionnaire based random sample of 520 Victorian GPs found that 19% reported managing an STI daily or weekly, 36% monthly, and 46% infrequently or never. Of STIs managed in the past month, 44% were human papillomavirus, 30% genital herpes, 14% genital chlamydia, and 12% non-specific urethritis.2 A study from Queensland of GPs with previous experience in diagnosing and managing STIs found that 60% reported having seen over 20 patients at risk of an STI in the previous 12 months and more than 90% had diagnosed at least one case of ano-genital warts, genital herpes, or chlamydia with 25% diagnosing more than six cases.3 Both studies are small, not nationally representative and used retrospective questionnaires. The data are subjective and dependent on the GP’s estimate of encountered cases. These are often overestimates.4 Data obtained at the time of patient encounter provides a better reflection of the actual situation. The Australian Morbidity and Treatment survey in general practice was carried out in 1991. Four hundred and ninety five GPs recorded details of all patient encounters for two 1 week periods, 6 months apart. Genital and reproductive problems were the fifth (10.1%) and eighth (7.0%) most frequently managed problem for women, while genital problems were the twelfth (2.5%) most common for men.5 However, these figures are only an indicator of STIs managed as they include www.stijournal.com well check-ups and symptoms or diagnoses that may not be associated with STIs. International research in this field is also limited. Studies from the United Kingdom have estimated that STIs are managed infrequently in general practice6–8 and based on the proportion of laboratory confirmed chlamydial infections that originate from GPs, it has been concluded that GPs seldom request chlamydia tests.9 The information and statistics division of the National Health Service in Scotland (ISD) has a continuous morbidity recording system consisting of 53 practices (population 307 741). These practices record the reason for contact for all direct encounters. In the year ending March 2000 there were 133 contacts for genital herpes with a prevalence rate of 0.6 per 1000 population, 462 contacts for genital warts with a prevalence of two per 1000, and 24 contacts for gonorrhoea with a prevalence of 0.2 per 1000.10 These figures are based on presumed infection and, because of the small numbers of cases, have considerable imprecision. In the United Kingdom, lack of adequate data from primary care is a major concern,11–13 particularly in light of the national strategy for sexual health and HIV that recommends an increasing role for general practice.14 Analysis of the frequency of STI problems managed by Australian GPs has been made possible by access to a database that records data from an ongoing cross sectional survey of GP activity. The aims of this study were to ascertain how frequently Australian GPs manage STIs, how STIs are managed in general practice, and to determine the characteristics of GPs who manage them. Abbreviations: AMS, Aboriginal Medical Services; BEACH, Bettering the Evaluation and Care of Health; GPs, general practitioners; STIs, sexually transmitted infections Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com Management of STIs METHODS The database Bettering the Evaluation and Care of Health (BEACH) is an ongoing cross sectional encounter based survey of general practice activity throughout Australia. The survey was established in April 1998 and the methods have been described in detail elsewhere.15 In summary, each GP in a random sample of approximately 1000 practising GPs per year, completes details about 100 consecutive GP-patient encounters on standardised paper recording forms. The encounter maybe the first visit for a particular problem or a follow up visit relating to a previously diagnosed condition. Data elements include GP age, sex, years in practice, sessions worked per week, size of practice, practice location, country of graduation, postgraduate general practice training, and FRACGP status. Patient information includes age, sex, cultural background, and up to three reasons for encounter. Up to four problems/diagnoses can be recorded as managed at the encounter. Management data include medication, pathology tests, imaging requests, and referrals. Patient reason for encounters and problems managed were classified according to the International Classification of Primary Care (version 2) (ICPC-2).16 Medications were classified according to an in-house classification, the Coding Atlas for Pharmaceutical Substances (CAPS) and to the Anatomical Therapeutic Chemical Classification Index.17 For the purpose of this study we have analysed only the actual STI diagnoses—syphilis, gonorrhoea, genital herpes, condylomata accuminata, and female trichomoniasis, and chlamydia. Separate codes for male chlamydia are not present in ICPC-2. As yet undiagnosed symptom labels were not included. BEACH data collected during the 36 month period from April 1998 to March 2001 were analysed. Data underwent post-stratification weighting by age (stratified by sex) and for activity level of participating GPs in order to improve representativeness of the data set. Statistical methods The database was analysed using SAS version 6.1218 with the encounter being the primary unit of analysis. Where events can only occur once in a consultation (for example, age, sex, Medicare item number) percentages are used to describe the distribution. If an event can occur more than once (for example, reasons for encounter, problem managed, or medications), then rates per 100 encounters are used. Secondary analysis of the data used x2 to calculate differences in GP characteristics and paired t test to calculate differences in patient age groups. RESULTS In all, 3030 GPs provided data on 303 000 encounters. There were only 521 STIs recorded (0.17 per 100 encounters). Viral STIs were by far the most common and included genital herpes (0.08 per 100 encounters) and genital warts (0.07 per 100 encounters). Bacterial and protozoal STIs were managed rarely—gonorrhoea (0.005 per 100 encounters), female trichomoniasis (0.005 per 100 encounters), female chlamydia (0.004 per 100 encounters), and syphilis (0.003 per 100 encounters). The breakdown by sex for the viral STIs revealed a preponderance of cases in women—genital herpes (2:1), and genital warts (1.3:1). Gonorrhoea was managed on only 15 occasions (six women, nine men) and syphilis on nine occasions (seven women, two men). National annual estimates during this 3 year period calculated using the BEACH data were 39 466 encounters for genital herpes, 24 933 encounters for genital warts, 1733 encounters for female trichomoniasis, 1700 encounters for gonorrhoea, 1266 encounters for female chlamydia, and 1033 213 for syphilis. Because of the small number of cases of bacterial and protozoal STIs, these figures should be interpreted with caution. Patient characteristics Of the 521 patients who had an STI managed, 329 (63.1%) were female and 189 (36.3%) male (missing which sex in three). In 350 (67.2%) patients the problem had previously been managed by a medical practitioner and 459 (88.1%) had been seen previously at the practice. Those in the 25–44 year old age group accounted for about half of both the men (56.6% n = 107) and women (50.5% n = 166). One in three (30.4% n = 100) of the women and one in five (19.6% n = 37) of the men were aged between 15 and 24. Age was missing for four patients. Thirty three (6.3%) were identified as being from a non-English speaking background and five as Aboriginal people or Torres Strait Islanders. The sex breakdown was not significantly different from the total of the patients at BEACH encounters (men 36.49% v 41.12%; women 63.51% v 58.88%: p = 0.112). However, STI patients were significantly younger than the total sample in BEACH (p = 0.005). Reasons for encounter (RFE) Two hundred and eighty four (54.8%) patients gave only one RFE, 145 (28.0%) gave two RFEs, and 89 (17.2%) three RFEs. Patients often described the RFEs in diagnostic terms— female condylomata acuminata (12.5 per 100 encounters, 95% CI 9.5 to 15.5), male condylomata acuminata (11.7 per 100 encounters, 95% CI 9 to 14.5), female genital herpes (10.4 per 100 encounters, 95% CI 7.8 to 12.9), and male genital herpes (5.57 per 100 encounters, 95% CI 3.9 to 7.3). Other frequent RFEs included a request for prescriptions (7.5 per 100 encounters, 95% CI 5.4 to 9.6), test results (6.7 per 100 encounters, 95% CI 4.8 to 8.6), female genital check-up (6.1 per 100 encounters, 95% CI 4.3 to 8.0). Patient management Although genital herpes was the most common STI to be managed, only five viral cultures, one herpes simplex virus (HSV) culture and three HSV serology tests were carried out during this time. Other tests were also uncommon and included 33 vaginal swabs for microscopy and culture, four cervical swabs, three urethral or penile swabs, 10 chlamydia tests, eight HIV, two syphilis, and two hepatitis B serology tests. Medication was prescribed at a rate of 56.1 per 100 STIs (95% CI 50.4 to 61.7). Antivirals accounted for 58.6% of medications (95% CI 51.6 to 65.5) and chemotherapeutics for topical use 16.7% (95% CI 0 to 36.4), reflecting the STIs encountered. Systemic aciclovir was prescribed as often as valaciclovir (n = 64; 22.0% of STIs v n = 67; 23.0%). Famciclovir, however, was only prescribed on 27 occasions (9.3%). Antibiotics, which were prescribed infrequently, included tinidazole (n = 9; 3.1% of STIs), metronidazole (n = 7; 2.4%), procaine penicillin (n = 4; 1.4%), ciprofloxacin (n = 4; 1.4%), azithromycin (n = 4; 1.4%), ceftriaxone (n = 3; 1.0%), doxycycline (n = 3; 1.0%), and amoxycillin (n = 2; 0.7%). At 20.0% of contacts with STI (95% CI 6.6 to 33.3) excision, destruction, or cauterisation took place. Counselling, education, or advice was documented at a rate of only 33 per 100 STI contacts. Of the 521 STIs managed, 34 were referred, 11 to gynaecologists, four to sexual health physicians, three to dermatologists, surgical specialist or non-specified specialist, two to urologists, a health professional, hospital or a clinic, and one to an obstetrician or a physician. www.stijournal.com Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com 214 Johnston, Britt, Pan, et al GP characteristics The characteristics of the 417 GPs (17.1%) who documented the management of the 521 STIs are compared with all BEACH GPs in table 1. GPs who diagnosed STIs were more likely to be female, younger, urban, have fewer years in practice, work fewer sessions per week, work in a larger group practice, have graduated in Australia and hold a fellowship of the RACGP than the BEACH cohort as a whole. DISCUSSION This study is the first national representative study of STI management in general practice in Australia. The results show that Australian GPs manage STIs infrequently and are more likely to deal with viral STIs than bacterial STIs. Each of the more frequently managed STIs was managed at rates of less than one per 1000 GP-patient encounters. In addition, the characteristics of general practitioners managing STIs were significantly different to those of the total BEACH GP sample. GPs managing STIs were more likely to be younger, female, work fewer sessions per week, work in multipractitioner practices, have graduated in Australia, and hold a fellowship of the Royal Australian College of General Practitioners (FRACGP). There are a number of possible reasons for the low management rate of STIs in general practice suggested by this study. Firstly, the prevalence of bacterial STIs in the community may be low and the frequencies in this study simply a reflection of this. This may be true for gonorrhoea and syphilis in the general population. Certain minority groups in Australia, in particular homosexual males and some Indigenous communities, have been noted to have higher levels of bacterial STIs than documented in the general population.19 20 These groups may be more likely to attend specialist services such as sexual health clinics or AMS or alternatively attend GPs with a specialised interest in the area. Secondly, these data only look at a snapshot of a patient’s overall management. GPs may be labelling the symptom or a syndrome such as cervicitis or urethritis and treating empirically rather than isolating a pathogen to give the definitive diagnosis. Evidence from other studies suggests that presumptive treatment is common practice and confirmatory laboratory tests are not always done.4 This study did not include symptom labels and this is reflected in the relatively low pathology test rate. Higher rates could be expected in the diagnostic rather than the post-diagnostic phase. Thirdly, bacterial STIs are often asymptomatic, especially chlamydia and gonorrhoea in females. In males urethral gonorrhoea is usually symptomatic; however if the infection is either rectal or pharyngeal this is not the case. Without screening, therefore, the infection will not be identified and not treated. Barriers to screening identified in general practice include the health seeking behaviour of those at highest risk,21 lack of opportunistic sexual history taking and therefore failure to identify individuals at risk,22 gaps in GPs’ knowledge, attitudes, behaviour, and practice,4 23 lack of appropriate facilities for screening and ‘‘Medicare barriers,’’ in particular discouragement of screening and the ‘‘three test rule’’—where the pathology laboratory is only able to claim a rebate for the three most expensive tests performed on a patient on any one day. What steps should be taken in order to optimise the diagnosis and management of STIs in general practice? Table 1 Comparison between general practitioners (GPs) who managed STIs and the BEACH cohort GP characteristics Sex Male Female Missing Age ,35 35–44 45–54 .55 Missing Years in general practice ,10 .10 Missing Sessions per week ,5 6–10 .10 Missing Size of practice Solo 2–4 GPs .4 GPs Missing Location of practice Urban Rural Country of graduation Australia Other Missing RACGP training programme Missing Hold FRACGP Missing STI GPs BEACH GPs p Values 205 (49.4%) 210 (50.6%) 2 2091 (69.4%) 922 (30.6%) 17 ,0.005 42 (10.1%) 162 (39.0%) 125 (30.1%) 86 (20.7%) 2 217 978 995 823 17 ,0.005 126 (30.7%) 286 (69.4%) 5 696 (9.2) 1093 (76.8%) 26 ,0.005 86 (21.2%) 273 (66.6%) 50 (12.2%) 7 439 (14.7%) 2017 (67.3%) 539 (18.0%) 35 ,0.005 45 (11.2%) 153 (38.0%) 205 (50.9%) 14 539 (18.5%) 1146 (39.2%) 1236 (42.3%) 109 ,0.005 317 (76.0%) 100 (24.0%) 2254 (74.4%) 776 (25.6%) NS 324 (79.0%) 65 (20.8%) 7 9 (2.2%) 14 169 (41.4%) 15 2239 (74.5%) 767 (25.6%) 24 351 (2.4%) 17 902 (30.1%) 31 ,0.005 (7.2%) (32.5%) (33.0%) (27.3%) ,0.005 ,0.005 RACGP = Royal Australian College of General Practitioners; FRACGP = Fellow of the Royal College of General Practitioners. www.stijournal.com Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com Management of STIs Improving public education and knowledge may encourage those at risk, whether they have symptoms or not, to seek screening and if necessary treatment. Strategies to ensure that the majority of GPs have the skills, knowledge, and confidence to manage STIs need to be developed and evaluated. Finally, in Australia, a national STI control strategy needs to be developed and initiated. The aims of this strategy should include—reducing the incidence of clinically apparent and undiagnosed STIs, reducing the transmission of STIs, and reducing the social stigma associated with STIs. Elements of this strategy should include providing clear information to the general public to enable people to make informed decisions about diagnosis, treatment and prevention of transmission, providing a range of easily accessible screening and management options (including general practice) for individuals with suspected STIs, setting standards for STI screening and management, and establishing priorities for future research thereby improving the evidence base for good practice in sexual health. Although medical services differ around the world, we believe that the findings from this study will have important implications in assisting the development of sexual health services in general practice in many parts of the world and, in particular, in the United Kingdom where the recently published House of Commons Health Select Committee inquiry into sexual health concluded that sexual health services were a shambles.24 In addition, despite the government’s sexual health strategy10 calling for more sexual health services to be delegated to primary care trusts (that is, GPs), there is little evidence to suggest that this is occurring.24 ACKNOWLEDGEMENTS During 1998–2001 the BEACH programme was funded by the Australian Commonwealth Department of Health and Ageing, the Commonwealth Department of Veterans’ Affairs, the National Occupational Health and Safety Commission, AstraZeneca (Australia), Roche Products Pty Ltd, Aventis Pharma Pty Ltd, and Janssen-Cilag Pty Ltd. ..................... Authors’ affiliations V J Johnston, A Mindel, Sexually Transmitted Infections Research Centre (STIRC), University of Sydney, Marian Villa, Westmead Hospital, Westmead, NSW 2145, Australia H Britt, Y Pan, AIHW General Practice Statistics and Classification Unit, University of Sydney, Acacia House, Westmead Hospital, Westmead, NSW 2145, Australia Conflict of interest: This article was researched, analysed and written as an independent analysis of data from Bettering the Evaluation and Care 215 of Health (BEACH) study. There was no conflict of interest for the authors in the preparation of this article. REFERENCES 1 Woolley PD, Chandiok S. Survey of management of genital herpes in general practice. Int J STD AIDS 1996;7:206–11. 2 Simms I, Hurtig A-K, Rogers PA, et al. Surveillance of sexually transmitted infections in primary care. Sex Transm Infect 2003;79:174–6. 3 Simms I, Nicoll A. Sexual health in England: a guide to national and local surveillance and monitoring data. London: Health Education Authority, 2000. 4 Catchpole M, Harris J, Renton A, et al. Surveillance of sexually transmitted infections: fit for a purpose? Int J STD AIDS 1999;10:493–4. 5 Department of Health. The national strategy for sexual health and HIV. London: DoH, 2001. 6 Mulvey G, Temple-Smith MJ, Keogh LA. Sexually transmissible diseases— knowledge and practices of general practitioners in Victoria, Australia. Genitourin Med 1997;73:533–7. 7 Dunne MP, George M, Byrne D, et al. The sexual health caseloads of general practitioners in Queensland. Venerology 1995;8:71–5. 8 Temple-Smith M, Keogh L, Mulvey G. Testing for Chlamydia and other sexually transmissible diseases in general practice in Victoria. Venereology 1997;10:14–18. 9 Sayer GP, Britt H. Sex differences in morbidity: a case of discrimination in general practices. Soc Sci Med 1996;42:257–64. 10 Commonwealth Department of Health and Aged Care (DHAC). General practice in Australia: 1996. Canberra: DHAC, 1996. 11 Estcourt CS, Higgins SP, Hull J, et al. Patients with genital warts: how are they managed by general practitioners? Int J STD AIDS 1996;7:221–3. 12 Ross JD, Champion J. How are men with urethral discharge managed in general practice? Int J STD AIDS 1998;9:192–5. 13 Ross JD, Sutherland S, Coia J. Genital chlamydia trachomatis infections in primary care. BMJ 1996;313:1192–3. 14 ISD Scotland National Statistics release ‘‘Genitourinary medicine in general practice’’, 2001. 15 Britt H, Sayer GP, Miller GC, et al. General practice activity in Australia 1998–99, AIHW Cat No GEP 2. Canberra: Australian Institute of Health and Welfare (General Practice Series no 2). 16 Classification Committee of the World Organization of Family Doctors (WICC). ICPC–2: International Classification of Primary Care. Oxford: Oxford University Press, 1997. 17 World Health Organization. Collaborating Centre for Drug Statistics Methodology (WHO). Anatomical Therapeutic Chemical (ATC) classification index with Defined Daily Doses (DDDs). January 1998 ed. Oslo: WHO, 1997. 18 SAS Institute Inc. SAS proprietary software release 6.12. Cary: SAS Institute Inc, 1996. 19 Donovan B, Bodsworth NJ, Rohrsheim R, et al. Increasing gonorrhoea reports—not only in London. [letter]. Lancet 2000;355:1908. 20 Miller PJ, Law M, Torzillo PJ, et al. Incident sexually transmitted infections and their risk factors in an Aboriginal community in Australia: a population based cohort study. Sex Transm Infect 2001;77:21–5. 21 Dickson N, Paul C, Herbison P. Where young people with multiple sexual partners seek medical care; implications for screening for chlamydial infection. Sex Transm Infect 1998;74:445–7. 22 Temple-Smith MJ, Mulvey G, Keogh L. Attitudes to taking a sexual history in general practice in Victoria, Australia. Sex Transm Infect 1999;75:41–4. 23 Marks C, Tideman R, Mindel A. The management of sexually transmitted disease comparing specialists and general practitioners in Australia. Venerology 1998;11:29–3. 24 House of Commons Health Select Committee. Report on sexual health. June 2003. (www.parliament.the-stationery-office.co.uk/pa/cm20023/cmselect/ cmhealth/69/6002.htm) Accessed 18 July 2003. www.stijournal.com Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com 324 Sex Transm Infect 2004;80:324–328 PostScript .............................................................................................. LETTERS If you have a burning desire to respond to a paper published in Sexually Transmitted Infections, why not make use of our ‘‘eLetters’’ option? Log onto the STI website (www.stijournal. com), find the paper that interests you, click on [Abstract] or [Full text], and send your electronic response by clicking on ‘‘eLetters submit a response’’. Providing your letter isn’t libellous or obscene, it will be posted within seven days. You can view recent eLetters by clicking on ‘‘Read eLetters’’ on our homepage. As before, the editors will decide whether to publish the eLetter in a futher print issue. HIV transmission among men who have sex with men through oral sex While the risk of transmission through oral sex for men who have sex with men (MSM) is low, discrepancies remain between study findings and there is uncertainty about the exact degree of risk.1 Between July 2001 and September 2003, a total of 4150 MSM were newly diagnosed with HIV infection in England, Wales, and Northern Ireland and reported to the Communicable Disease Surveillance Centre in London. Reports for 1359 cases received during this time included the question ‘‘Does the patient believe himself to have been infected through oral sex?’’ The remaining 2791 cases had only laboratory reports or earlier clinician report forms where this question was not asked. The oral sex question was answered for 688 (50.6%) of the 1359 cases, of which for 625 (90.8%) the response was no, and yes for 63 (9.2%) cases. For 671 cases this information was not recorded even though the question was included on the form. All 63 cases where the patient believed himself to have been infected with HIV through oral sex were further investigated by a discussion with the clinician or healthcare provider. From these further discussions during the follow up, 27 (42.8%) cases were believed to have been infected from unprotected anal intercourse. Of the remaining 36 cases, 16 (2.3%) claimed to have had only oral sex as their risk for acquiring HIV, with 20 (2.9%) cases always reporting protected anal sex but unprotected oral sex. Previous negative testing history and HIV status of partners was taken into account when discussing possible HIV risk with clinicians or healthcare providers. It is difficult to quantify oral sex risks and this could be an obstacle to accuracy1–3; none of these individuals were re-interviewed for this study and risk was assessed by clinician and note review only. There may be recall difficulties surrounding condom use, including whether they were used, or if used, coming off or splitting, or brief anal-penile contact that was not considered relevant or www.stijournal.com remembered. In addition, there was limited information about whether ejaculation had occurred or about breaks in the oral mucosa. However, 16 cases reported no anal sex and 20 cases reported only protected anal sex and unprotected oral sex. In total this represents 5.2% of those MSM reports where the question was answered. We are aware that, for half, the question was not answered, and if we classified those reports as not infected through oral sex, then 2.6% (36 of 1359) were probably infected through this route. The indication given by these UK surveillance data is that oral sex carries a small but real risk. V L Gilbart, B G Evans, S Dougan Communicable Diseases Surveillance Centre, 61 Colindale Avenue, London NW9 5EQ, UK Correspondence to: Ms Victoria Gilbart, Communicable Diseases Surveillance Centre, 61 Colindale Avenue, London NW9 5EQ, UK; Vicky.gilbart@hpa.org.uk doi: 10.1136/sti.2004.009217 Accepted for publication 7 January 2004 References 1 Rothenburg RB, Scarlett M, del Rio C, et al. Oral transmission of HIV. AIDS 1998;12:2095–105. 2 Richers J, Grulich A, Ellard J, et al. HIV transmission among gay men through oral sex and other uncommon routes: case series of HIV seroconverters, Sydney. AIDS 2003;17:2269–71. 3 Robinson EK, Evans BG. Oral sex and HIV transmission. AIDS 1999;13:737–8. The correct approach to modelling and evaluating chlamydia screening A recent systematic review of economic evaluations suggests that screening for genital chlamydia infection is ‘‘cost effective.’’1 We are concerned about how the authors reached this conclusion since the reviewers did not take into account the fact that Chlamydia trachomatis is infectious. The methodological problems arising from this fundamental flaw raise questions about the validity of the conclusion. The correct model to use in the evaluation of an infectious disease must be capable of encompassing all its effects, including the potential for transmission. Bernoulli first reported such transmission dynamic models in the 18th century.2 The wide misuse of static, as opposed to transmission dynamic, models has been noted in the economics literature on vaccination programmes,3 but the message has been slow to transcend to the economics literature on sexually transmitted infections, with a few notable exceptions.4 In the case of screening for genital chlamydia, someone who is successfully treated might be re-infected; the benefits of treatment in preventing long term sequelae will be lost, and the person could continue to infect others. If they are successfully treated without re-infection, however, they will not transmit infection. Since the two possibilities have opposing effects on the number of cases, the direction of change in the cost effectiveness ratio is uncertain; it could overestimate or underestimate the true cost effectiveness. Economic evaluations that do not incorporate these effects are, therefore, very unlikely to model the outcomes of a chlamydia screening programme accurately. Although the use of objective criteria to assess the quality of identified papers was praised in a recent STI editorial,5 the checklist used by Honey et al1 is outdated and was not applied appropriately for an infectious disease. This led the authors to include papers whose results might be unreliable. The use of more recent and widely used guidelines, which ask questions about the choice of model type and the justification for the key parameters on which the model is based,6 may have drawn attention to the problems of static models. Furthermore, the review included studies that used ‘‘cost per case detected,’’ which is an inadequate outcome for screening programmes because it does not take into account resource implications associated with the course of action taken by individuals after case detection. We have recently concluded our own systematic review of economic analyses of screening programmes for genital chlamydia infection, as part of the ongoing Chlamydia Screening Studies project (ClaSS). While the majority of studies we identified had used an incorrect modelling approach, we did identify a full economic evaluation that had used a dynamic model to evaluate chlamydia screening. This was identified by Honey et al. but excluded because they thought that it did not fulfil their inclusion criteria.1 We propose that all future economic evaluations of chlamydia screening should use a dynamic modelling approach. A consensus panel to develop guidelines for the conduct of economic evaluations of interventions for sexually transmitted infections could take this recommendation into account.6 T Roberts, S Robinson, P Barton, S Bryan, A McCarthy, J Macleod, M Egger, N Low Health Economics Facility, HSMC, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham B15 2RT, UK Correspondence to: T Roberts, Health Economics Facility, HSMC, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham B15 2RT, UK; t.e.roberts@bham.ac.uk doi: 10.1136/sti.2003.008458 Accepted for publication 19 November 2003 Conflict of interest: The authors are all members of the Chlamydia trachomatis Screening Studies (ClaSS) Working Group. Part of the remit of this group is to conduct a systematic review of economic studies of Chlamydia trachomatis screening and to construct a model with which to evaluate the cost effectiveness of chlamydia screening. References 1 Honey E, Augood C, Templeton A, et al. Cost effectiveness of screening for Chlamydia trachomatis: a review of published studies. Sex Transm Infect 2002;78:406–12. 2 Bernoulli D. Mathematical and physical memoirs, taken from the registers of the Royal Academy of Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com PostScript 3 4 5 6 325 Sciences for the year 1760: an attempt at a new analysis of the mortality caused by smallpox and the advantages of inoculation to prevent it. In: Bradley L, ed. Small pox inoculation, an eighteenth century mathematical controversy. Translation and critical commentary. Nottingham: University of Nottingham, 1971. Brisson M, Edmunds WJ. Economic evaluation of vaccination programs: the impact of herdimmunity. Medical Decision Making 2003;23:76–82. Welte R, Kretzschmar M, Leidl R, et al. Costeffectiveness of screening programs for Chlamydia trachomatis: A population based dynamic approach. Sex Transm Dis 2000;27:518–29. Mehta SD, Shahmanesh M, Zenilman JM. Spending money to save money, cost effectiveness analysis to advocate Chlamydia trachomatis screening. Sex Transm Infect 2003;79:4–6. Drummond MF, Jefferson TO. Education and debate. Guidelines for authors and peer reviewers of economic submissions to the BMJ. BMJ 1996;313:275–83. Haryana state in India, still a low HIV prevalence state In Haryana, India, with a geographical area of 27 632 square miles, an HIV sentinel infected (OR 2.68 (95% CI 1.1 to 6.7)). When we combined the literacy status for both men and women, the HIV prevalence was statistically significant among the literate of more than fifth grade (p value = 0.0416) but was not found to be significant when combined for ANC attendees. School or college education, therefore, does not have any impact on this epidemic. Emphasis has to be given to educate the general public about AIDS. Among the STD clinic attendees presenting with genital ulcer, HIV reactivity (3.9%, 7/181) and VDRL reactivity (11.6%, 21/181) were found to be statistically significant (p,0.05, x2 test used). Therefore, in India, where the overall level of HIV is still low, a high level of STDs in certain states makes for a continuing potential for the epidemic to become generalised among all sexually active adults. Differences across the states may just be a matter of time.4 As per the sentinel surveillance data in the year 1998, there were seven moderate prevalence states (prevalence among ANC attendees ,1% but prevalence among the STD clinic attendees .5%) and 19 states were of low prevalence compared to two states only with moderate prevalence rates and 24 states surveillance was carried out, on a regular basis (1998–2002), on consecutive serum samples of 400 antenatal clinic (ANC) attendees (three sites) and 250 sexually transmitted diseases (STD) clinic attendees (four sites). This was done for each 12 week period per year as unlinked anonymous testing with one of the ELISA/rapid/simple tests. A sample that was positive with two tests of different assays was considered HIV positive. The other STDs were diagnosed clinically and using appropriate laboratory tests.1 2 Of the 7933 men and women who participated in the HIV sentinel surveillance from 1998–2002, 15 (0.3%) of 5200 ANC attendees and 48 (1.8%) of 2733 STD clinic attendees had HIV. Though HIV prevalence is still below 1% among the ANC attendees, a gradual increase over these 5 years has been observed though statistically it was not found to be significant (table 1). With increasing HIV infection among antenatal women, paediatric AIDS is poised to become an important public health problem.3 4 The odds ratios (ORs) of HIV infection for men compared to women decreased by age; men aged 20–29 years were nearly thrice as likely as women the same ages to be HIV Table 1 HIV prevalence rates for the attendees tested in sentinel surveillance programme, 1998–2002 Characteristics Age groups (years) 15–19 20–29 30–44 .45 Sentinel year Feb-Mar 1998 Aug-Oct 1998 Aug-Oct 1999 Aug-Oct 2000 Aug-Oct 2001 Aug-Oct 2002 Residence Urban Rural Population Migrant Non-migrant Literacy status Lliterate Literate till 5th grade Literate till 12th grade Graduation not done Occupation of spouses
Business Industrial and factory workers Service Agriculture and unskilled workers Truck/auto/taxi driver Hotel staff Unemployed Students Syndrome Genital ulcer Urethral/cervical discharge Genital ulcer and discharge Genital warts Antenatal clinic attendees STD clinic attendees HIV reactive Men Women % (No)* p Value % (No) % (No) Men/women ratio (95% CI) p Value1 0.3 0.3 0.2 0 (383) (4171) (630) (16) ns
ns ns ns 1.8 2.5 2.8 1.5 (113) (756) (432) (132) 0 0.9 1.3 0 (57) (639) (547) (57) 2

2.68 (1.1 to 6.7) 2.80 (1.1 to 6.9) 2 ns 0.0272 ns ns 0 0 0 0.08 0.4 0.6 (2001–2) 0.4 0.7 (2001–2) 0.9 0.5 (2001–2) 0.5 0.6 0.5 0.4 (2001–2) 0.4 0.3 (400) (400) (400) (1200) (1200) (1600) ns ns ns ns ns ns (211) (123) (274) (410) (415) 3.1 0 2.3 0.7 0.7 (32) (10) (221) (454) (578) 1.06 2 0.97 2.21 3.13 ns ns ns ns 0.0434 (1573) (1227) ns ns (543) (515) 1.0 1.2 (659) (630) 0.87 (0.3 to 2.7) 1.99 (0.8 to 4.8) ns ns (224) (2576) ns ns (23) (392) 0 0.7 (41) (537) ns ns ns ns (88) (65) (193) (69) 0.9 0.9 0.5 0 (220) (114) (184) (60) 2 3.08 (1.0 to 9.9) 2002 2 3.51 (0.3 to 37.9) 3.81 (0.4 to 33.8) 2 ns 0.0469 (859) (524) (1173) (244) ns ns ns ns (435) (325) ns ns 3.3 5.7 2.2 1.5 2.2 (2000–2) 1.0 2.5 (2002) 0 2.3 (2002) 0 3.1 2.1 4.3 (2002) 1.8 3.0 (56) (33) 20.0 (5) 2 0.15 (0.0 to 2.1) ns ns 0.2 0.7 (539) (1241) ns ns 1.1 1.3 (94) (153) 0 0 (29) (10) 2 2 ns ns 0.6 0 0 0 (160) (6) (60) (34) ns ns ns ns 16.7 0 0 2.2 (18) (1) (15) (45) 0 (1) 0.6 0 (522) (11) 2 2 2 2 ns ns ns ns 2.5 1.0 3.4 2.4 (403) (511) (59) (85) 2.7 0.9 1.5 0 (148) (1043) (66) (32) 0.92 (0.3 to 2.9) 1.13 (0.4 to 3.4) 2.24 (0.2 to 24.0) 2 ns ns ns ns (0.1 to 0.3) (0.3 to 3.1) (0.6 to 8.8) (1.0 to 10.1) *Number of attendees.
Among the antenatal clinic attendees, the majority of the occupations stated are those of the spouses with only occasional women having in that occupation. p Value .0.05 (ns
= not significant) in all the characteristics (x2 test used).

Men/women ratio (95% CI) couldn’t be calculated. 1p Value for test between sexes (x2 test used). www.stijournal.com Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com 326 PostScript with low HIV prevalence rates (prevalence among the STD clinic attendees ,5%) in the year 2001 while six states stayed as high prevalence states (prevalence among ANC attendees .1%). Haryana is still maintaining itself in a low level epidemic category. It is speculated that the effect of STD control and screening of ANC attendees for HIV transmission may decrease with the maturation of the HIV epidemic as experienced in trials in Tanzania and Uganda.5 Therefore, we should increase intervention programmes in all high risk groups as well as in the general population of this city while it is still in the early epidemic phase to ensure that this cost effective opportunity is not missed. Acknowledgements The authors wish to thank the senior technician in charge, Shri Satpal Singh, for his assistance in the fieldwork and laboratory procedures throughout this study. The statistical help provided by Shri R C Goel, PGIMER, Chandigarh, is duly acknowledged. We also thank Professor Narottam Sharma from the Regional Institute of English Chandigarh, UT for proof reading of the manuscript. We also acknowledge National AIDS Control Organisation (NACO) for its continuing guidance and the supply of free kits for HIV testing. Contributors DRA, BA, protocol development for field implementation, final approval of manuscript; VG, PG, field implementation of clinical and laboratory procedures, writing; DRA, BA, VG, VGu, analysis and interpretation, critical reviewing of manuscript. D R Arora Department of Microbiology, Voluntary Counselling and Testing Centre for AIDS, Post-graduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana, India V Gautam Department of Microbiology, Government Medical College and Hospital, Chandigarh, India P S Gill Department of Microbiology, Post-graduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana, India B Arora Department of Pathology, Post-graduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana, India Increased numbers of acute hepatitis C infections in HIV positive homosexual men; is sexual transmission feeding the increase? Although the principal mode of hepatitis C (HCV) transmission in the United Kingdom is injecting drug use (IDU), the risk for a third of infections is unknown.1 The contribution of sexual transmission between men who have sex with men (MSM) to the spread of hepatitis C is unclear, however evidence is accumulating that both co-infection with HIV2 and the presence of other sexually transmitted infections (STIs) facilitate sexual transmission of HCV.3 With the reported increases in unsafe sex and STIs in HIV positive MSM we questioned whether these circumstances may lead to an increase in the number of HCV infections. This study was undertaken to determine whether within our clinics, changes in the number of individuals being diagnosed with acute HCV infection were occurring and to ascertain risk factors for acquisition in these individuals. A case note review of all patients within the HIV and sexual health clinics of St Stephen’s Centre with diagnosed acute HCV infection between January 1997 and December 2002 was performed. Patients newly diagnosed with HCV were identified from departmental computer records. Cases were defined as individuals with a newly positive and a previous negative HCV antibody test. Where negative tests had been performed more than a year earlier, testing of stored samples was undertaken to determine more precise timing of HCV seroconversion. Testing was done using the Monolisa antiHCV version 2 enzyme immunoassay. Twenty six male (all MSM) and one female case were identified; median age was 34 years. Twenty five individuals were HIV positive. The median time between negative and positive HCV antibody tests was 5 months (interquartile range 3–10 months). There was a significant increase in HCV seroconversions over the study period (see fig 1). V Gupta Department of Microbiology, Voluntary Counselling and Testing Centre for AIDS, Government Medical College and Hospital, Chandigarh, India Correspondence to: Dr V Gautam, 3243/21 D, Chandigarh, India-160022; r_vg@yahoo.co.uk doi: 10.1136/sti.2003.008672 Accepted for publication 2 December 2003 References 1 Arora B. Retroviridae. In: Arora DR, ed. Textbook of microbiology. 2nd ed. New Delhi: CBS Publishers, 2003:555–70. 2 Haryana AIDS Control Society. Specialist’s training & reference module. Panchkula, Haryana: India: NACO, NACP-II, 1999–2004. 3 National AIDS Control Organization (NACO). HIV estimates for year 2001. New Delhi: NACO, (www.naco.nic.in). 4 Park K. Park’s textbook of preventive and social medicine, 16th ed. Jabalpur: Banarsidas Bhanot Publishers, 2000:257–66. 5 Grosskurth H, Gray R, Hayes R, et al. Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials. Lancet 2000;355:1981–7. www.stijournal.com Figure 1 Changing incidence of documented HCV seroconversion. Test for trend p value using Poisson regression p,0.001. Error bars are 95% CI. Date of seroconversion was taken as the date of the first positive HCV antibody test. The indications for HCV testing were the development of abnormal alanine transaminase (ALT) (21), recent IDU (two), sexual contact with HCV positive partner (one), and symptomatic seroconversion (three). Of those tested because of newly abnormal liver function tests (LFTs), 18 were asymptomatic. LFTs were performed as part of routine HIV follow up. There was no increase in HCV tests performed in HIV positive individuals with ALT levels more than 100 IU/l over the study period; however, the percentage of positive HCV tests increased from 0.6 to 9.3 (p value using x2 test for trend: ,0.001). Risks for acquisition of HCV were recent unprotected anal or vaginal sex (21) and IDU (two), while in four there were no documented risk factors. Nine individuals were diagnosed with infectious syphilis either concurrently (three) or in the year before HCV seroconversion. Of the HIV positive patients 15 were on antiretroviral therapy (ARV) and 11 had a viral load of less than 50 copies/ml. The median CD4 count was 359 cells 6106/l. Having multiple sexual partners, a history of STIs, and certain sexual practices have been associated with HCV infection. Reported increases in HCV seroconversion among HIV positive MSM in association with high risk sexual behaviour (unprotected anal sex, fisting, and rimming) suggests an interaction between HIV and sexual practice.4 As HCV plasma viraemia is higher in co-infected patients5 and correlates with that in saliva and semen, this may facilitate sexual transmission of HCV. Furthermore, there is evidence that ARV treatment may be associated with increases in HCV RNA levels.6 While retrospective assessment of factors may be problematic, features of this study make us more confident of attributing risk to sexual activity. Data were collected in both general HIV and specialist hepatitis clinics, and also most patients were under long term follow up allowing cumulative recording of risks particularly those relating to IDU. Although it is possible that increased numbers result from changing HCV testing thresholds there was no evidence of this when we examined HCV tests performed to investigate those with abnormal LFTs, the commonest scenario leading to diagnosis. As the ALT trigger was present in the HIV positive group and not in the sexual health clinic attendees, the numbers from this source may be under-represented. Determining the associated factors for transmission of HCV is critically important in order to introduce targeted screening and prevention interventions. As 85% of infected patients become chronic carriers and treatment of acute hepatitis C leads to high clearance rates, these strategies may be crucial in reducing the carrier pool of HCV, further transmissions and the risk of cirrhosis and hepatoma. The study numbers are small and may represent a pocket of infection not indicative of increased risks in larger populations. However, the manner in which these infections parallel recent increases in STIs gives cause for the concern that risks may be more generalised. Further studies are needed to clarify this trend. R Browne, D Asboe, Y Gilleece, M Atkins, S Mandalia, B Gazzard, M Nelson St Stephens Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com PostScript 327 Correspondence to: Dr Rita Browne, St Stephens Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK; rita.browne@chelwest.nhs.uk doi: 10.1136/sti.2003.008532 Accepted for publication 27 November 2003 References 1 Zeuzem S, Teuber G, Lee JH, et al. Risk factors for the transmission of hepatitis C. J Hepatol 1996;24(Suppl 2):3–10. 2 Filippini P, Coppola N, Scolastico C, et al. Does HIV infection favour the sexual transmission of hepatitis C? Sex Transm Dis 2001;28(12):725–9. 3 Marx M, Murugavel K, Tarwater P, et al. Association of hepatitis C virus infection with sexual exposure in southern India. Clin Infect Dis 2003;37:514–20. 4 Fletcher S. Sexual transmission of hepatitis C and early intervention. J Assoc Nurses AIDS Care 2003, Sep–Oct;14(Suppl 5):87S–94S. 5 Matthews–Greer J, Caldito G, Adley S, et al. Comparison of hepatitis C viral loads in patients with or without human immunodeficency virus. Clin Diagn Lab Immunol 2001;8(4):690–4. 6 Babik JM, Holodniy M. Impact of highly active antiretroviral therapy and immunologic status on hepatitis C virus quasispecies diversity in human immunodeficiency virus/hepatitis C viruscoinfected patients. J Virol 2003;77:1940–50. Transmission of Neisseria gonorrhoeae from a toilet seat In August 2003 a prepubescent 8 year old girl presented with a sudden onset history of a non-irritating, odourless heavy green vaginal discharge which had developed overnight. She had arrived back in Sydney approximately 24 hours earlier by an international air flight following an overseas holiday with her mother and two adolescent siblings. The family had spent 72 hours in transit flying from Rome to Sydney via Moscow. The child was taken initially to her family doctor and a heavy growth of Neisseria gonorrhoeae was isolated. The organism was resistant to both penicillin and ciprofloxacin. One week later, following an initial course of antibiotics, the child was referred to the author for assessment of possible sexual abuse and ongoing management of the N gonorrhoeae infection. Before boarding a flight to Moscow the family had spent 3 days in a hotel, sightseeing and the previous 2 days with relatives. During the 8 days before arriving in Sydney, the mother had unusually close contact with the child, had shared a bedroom with her, and had accompanied her almost continually. The child’s behaviour and demeanour had shown no change and both the child and the siblings were asymptomatic. When questioned by her mother, the child strongly denied any history of genital contact. The flights to and from Moscow were noted to be full with no spare seats. Both the mother and the child stated that there were queues to use the toilets during both flights and that by the end of the flights the ‘‘toilets were very dirty.’’ The mother stated that when the child used a public toilet the child always wiped the seat with toilet paper before using it. The child confirmed this. She said her fingers occasionally became dirty while wiping the seat. Genital examination of the child revealed no significant redness of the introitus or physical abnormality. She had an intact annular hymen; however, the absence of genital injury has no relevance in making a diagnosis that excludes sexual abuse.1 As part of the routine investigation, the matter was reported the New South Wales Department of Community Services and all family members were tested for N gonorrhoeae and were negative. It is important that all cases of N gonorrhoeae in children be fully investigated for sexual abuse, and reported to the relevant child protection authorities. There is no doubt that almost all gonococcal vaginal infections in prepubertal children are sexually transmitted,2 and this may include those previously reported as non-sexual.3 However it is also accepted that cases of non-sexual transmission of N gonorrhoeae in children do occur,4 but proof beyond all doubt can be very difficult to document scientifically. On the basis of the demeanour of the child, reports of increasing rates of gonorrhoea in the former Soviet Block countries,5 the incubation period for symptomatic N gonorrhoea, the history from the mother and her unusually close supervision of the child, as well as the child’s known behaviour in public toilets, it is the belief of the author that the child most probably contracted the infection via autoinoculation while using a mixed toilet in a crowded aeroplane. L Dayan Sexual Health Services, Northern Sydney Health, Clinic 16; Block 3, Royal North Shore Hospital, Pacific Highway, St Leonards; Sydney, Australia 2065; ldayan@doh.health.nsw.gov.au doi: 10.1136/sti.2003.008714 Accepted for publication 5 December 2003 References 1 Heger A, Ticson L, Velasquez O, et al. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Negl 2002;26:645–59. 2 Hammerschlang M. Sexually transmitted diseases in sexually abused children: medical and legal implications. Sex Transm Infect 1998;74:167–74. 3 Potterat JJ, Markewich GS, Rothenberg R. Prepubertal Infections with Neisseria gonorrhoeae: clinical and epidemiological significance. Sex Transm Infect 1978;5:1–3. 4 Lipsitt HJ, Parmet AJ. Nonsexual transmission of gonorrhoea to a child. (Letter) N Engl J Med 1984;311:470. 5 Borisenko KK, Tichonova LI, Renton AM. Syphilis and other sexually transmitted infections in the Russian Federation. Int J STD AIDS 1999;10:665–8. undertaken with the aim to find the prevalence of C trachomatis infection in male patients with NGU attending the STD clinic of a major city hospital in north India. After obtaining informed oral consent, 90 male patients (age 18–55 years) clinically suspected to have urethritis and attending the STD clinic at Safdarjang Hospital, New Delhi were enrolled. Of these, 85 NGU patients were included in the study on the basis of microscopic examination of urethral swab specimens for the presence of .10 polymorphonuclear neutrophils/high power field and negative results for Neisseria gonorrhoeae. None of the patients showed genital lesions. The patients belonged to various socioeconomic groups and the majority of them admitted to having extramarital heterosexual contact. The specimens were collected using sterile cotton tipped swabs (Hi Media, Mumbai, India) from the urethra of each patient after removing the secretions/discharge. The samples were collected in vials containing phosphate buffered saline for screening by a plasmid specific polymerase chain reaction (PCR) assay (517 bp)1 and confirmation by culture in McCoy cell line followed by direct fluorescent assay (DFA) (Microtitre, Syva Corporation, Palo Alto, CA, USA) on infected coverslips.4 Urethral C trachomatis infection was found by PCR (fig 1) and culture in 20 (22.3%) and 21 (24.7%) symptomatic male NGU patients, respectively. Further, chlamydial infection was most common (27.6%; statistically nonsignificant) in men in the 26–35 years age group. In an earlier hospital based study on male NGU patients reported from India, C trachomatis and Trichomonas vaginalis were the most common pathogens found by culture in urethral discharge specimens, being responsible for 18% and 19% cases, respectively.2 Another study from Chennai, India reported the prevalence of C trachomatis infection in male and female genital swab specimens as 18.9% and 32.2% by culture and PCR, respectively.3 Chlamydia and Ureaplasma urealyticum were the most common infecting and co-infecting pathogens (51.5% by PCR in first void urine and 45.6% by culture in intraurethral swab specimens, respectively) in male patients with NGU attending an Israeli STD clinic.5 In a study from Turkey, the prevalence of C trachomatis and N gonorrhoeae (screened by ligase chain reaction in either Detection of Chlamydia trachomatis by polymerase chain reaction in male patients with non-gonococcal urethritis attending an STD clinic Genital infection with Chlamydia trachomatis (35–50%) is the single most identifiable cause of non-gonococcal urethritis (NGU) in heterosexual men and may have serious consequences, not only for men but for their partners. In India, a high prevalence of genital C trachomatis infection has been reported in women.1 However, there is considerably less information on male chlamydial infection.2 3 There is a definite need for reliable screening of C trachomatis genital infection in men in order to prevent underdiagnosis of genital chlamydial infection and to facilitate better clinical management of this infection in India. This study was Figure 1 Detection of Chlamydia trachomatis by polymerase chain reaction in 1% agarose gel electrophoresis using 517 bp plasmid primer. Lane 1 is DNA marker. Lanes 2–6 show amplification of C trachomatis. Lane 8 is a negative control. Lane 7 is a positive control for C trachomatis. www.stijournal.com Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com 328 PostScript urethral swabs or first void urine) among men with symptomatic urethritis was 15.7% and 9.4%, respectively.6 This should be viewed with concern particularly in developing countries like India where screening for C trachomatis is not done on a routine basis and, hence, extensive screening should be conducted for detection of genital C trachomatis infection in men using sensitive and specific molecular assays like PCR. V Vats, S Rastogi, A Kumar, M Ahmed, V Singh, A Mittal Institute of Pathology (ICMR), Safdarjang Hospital Campus, Post Box no 4909, New Delhi 110 029, India R K Jain, J Singh Department of Sexually Transmitted Diseases (STD), Safdarjang Hospital, New Delhi 110 029, India Correspondence to: Dr Aruna Mittal, Institute of Pathology (ICMR), Safdarjang hospital campus, Post Box no 4909, New Delhi, 110 029, India; amittal_iop@yahoo.com doi: 10.1136/sti.2003.008839 Accepted for publication 30 January 2004 References 1 Singh V, Rastogi S, Garg S, et al. Polymerase chain reaction for detection of endocervical Chlamydia trachomatis infection in Indian women attending gynaecology outpatient department. Acta Cytol 2002;46:540–4. 2 Bhujwala KA, Seth P, Gupta A, et al. Nongonococcal urethritis in males: a preliminary study. Ind J Med Res 1982;75:485–8. 3 George JA, Panchatcharam TS, Paramasivam R, et al. Evaluation of diagnostic efficacy of PCR methods for Chlamydia trachomatis infection in genital and urine specimens of symptomatic men and women in India. Jpn J Infect Dis 2003;56:88–92. 4 Mittal A, Kapur S, Gupta S. Chlamydial cervicitis: role of culture, enzyme immunoassay and Giemsa cytology in diagnosis. APMIS 1993;101:37–40. 5 Srugo I, Steinberg J, Madeb R, et al. Agents of non-gonococcal urethritis in males attending an Israeli clinic for sexually transmitted diseases. Isr Med Assoc J 2003;5:24–7. 6 Agacfidan A, Moncada J, Aydin D, et al. Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in Turkey among men with urethritis. Sex Transm Dis 2001;28:630–2. BOOK REVIEW Letting Them Die—Why HIV/AIDs prevention programmes fail By Catherine Campbell. Pp 214; £40.00 (cloth) £12.95 (paper). Oxford: James Currey, September 2003. ISBN 0-85255-867-8 and 0-85255-868-6. What is going on with HIV in South Africa? The epidemic escalates with no sign of l d k h h www.stijournal.com slowing down, making the country the worst affected in the world. The government continues to try and find excuses not to deliver either treatment or prevention programmes. The sense of stigma is so palpable that ignorance of serostatus carried to the grave seems to be the usual way of living with the virus. This book tells the story of an HIV intervention project in Carletonville, a mining area near Johannesburg, where mineworkers and female sex workers eke out a day to day existence in which overindulgence in alcohol and unprotected sex appear to be the norm. It tells a salutary tale of a project conceived optimistically that gets dragged down through petty arguments, jealousy, and mistrust but still emerges to provide fresh insights into how to tackle the epidemic. Working in HIV in South Africa has always been full of challenges and, based on the story told here, those challenges would appear to be increasing. The author (a social scientist and member of the project research team) reports not only the successes, but also, more bravely, the failures of the project. She sets out her stall to tackle HIV through a project focusing at the community level. The plan was to have a project directed by stakeholders who would work together as a group and develop guiding principles that local HIV affected communities could use to support both individuals and promote HIV prevention programmes among female sex workers, miners, and youth. Unfortunately, the mine groups didn’t cooperate and other individuals saw themselves as just that, individuals rather than members of a cohesive, homogeneous community. Peer education, a major component of the project, faced many difficulties. With the benefit of hindsight, it seems as though many of the important stakeholders did not perceive adequate ownership of the project and became disillusioned early on leaving most of the day to day running to those employed by the project directly. The book is well written and clear and is recommended reading for anyone contemplating a large scale HIV prevention project, whether as a planner, implementer, or evaluator. The book explains social science terminology succinctly for those with limited knowledge of the discipline. It also demonstrates and describes very well that what works in one part of Africa will not necessarily work elsewhere, and that initial local assessment at the design stage of a large scale project is paramount. As HIV continues to spread outside the high risk groups, the need to educate at the community level also increases but the former group should not be forgotten. A combination of both strategies is probably the best approach. The reality is that, although the HIV epidemic in South and southern Africa has come a long way, there is still some distance to go. Hopefully, those involved in HIV project management will pick up the lessons set out in this excellent little book. N O’Farrell Pasteur Suite, Ealing Hospital, London UB1 3HW, UK; ofarrell@postmaster.co.uk CORRECTION doi: 10.1136/sti.2003.006957corr1 The reference list of the paper by V J Johnston, H Britt, Y Pan, and A Mindel, entitled ‘‘The management of sexually transmitted infections by Australian general practitioners’’ (Sex Transm Infect 2004;80:212–5), was published incorrectly. The correct reference list can be found as a data supplement to the article online at http://www.stijournal. com/cgi/content/full/80/3/212/DC1. NOTICES 22nd International Papillomavirus Conference and Clinical Workshop This will be held 29 April to 6 May 2005 in Vancouver, British Columbia, Canada. Topics will include animal papillomaviruses, diagnosis, epidemiology, HPV associated neoplasia in the developing world, immunology, molecular pathogenesis, natural history, screening, transcription, and treatment. For more information please contact: 22nd IPC Secretariat, C/o Venue West Conference Services Ltd, #645-375 Water Street, Vancouver, BC V6B 5C6, Canada; tel: +1 604 681 5226; fax: +1 604 681 2503; email: congress@venuewest.com; website: www. hpv2005.org. 16th Biennial Meeting of the ISSTDR The 16th Biennial Meeting of the International Society for Sexually Transmitted Diseases Research (ISSTDR) will be held 10–13 July 2005 in Amsterdam, The Netherlands. The meeting will be organised jointly by Dutch and Belgian STD researchers. For more information please visit www.isstdr. org. Answers to MCQs on p 320 (1) a (2) c (3) b (4) c (5) c (6) d (7) d (8) a (9) d (10) b Downloaded from sti.bmj.com on July 15, 2011 - Published by group.bmj.com The management of sexually transmitted infections by Australian general practitioners V J Johnston, H Britt, Y Pan, et al. Sex Transm Infect 2004 80: 212-215 doi: 10.1136/sti.2003.006957 Updated information and services can be found at: http://sti.bmj.com/content/80/3/212.full.html These include: Data Supplement "CORRECT Reference List" http://sti.bmj.com/content/suppl/2004/07/13/80.3.212.DC1.html References This article cites 12 articles, 6 of which can be accessed free at: http://sti.bmj.com/content/80/3/212.full.html#ref-list-1 Article cited in: http://sti.bmj.com/content/80/3/212.full.html#related-urls Email alerting service Topic Collections Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. 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