Comparison of risk factors for four sexually transmitted infections: results from a study of attenders at three genitourinary medicine clinics in England

Human Papillomavirus and Genital Disease in Men: What We Have Learned from the HIM Study

It is currently recognized that in addition to the major impact of human papillomavirus (HPV) infection in females, HPV causes considerable disease in men at the genitals, anal canal, and oropharynx. Specifically, genital HPV infections may progress to genital warts and penile carcinoma. Although studies concerning the natural history of HPV infections and associated neoplasias have mainly focused on women, during the last 2 decades considerable attention has been given in further understanding these infections in men. The HIM (HPV infection in men) Study, the only prospective multicenter study of male HPV natural history, consisted of a large prospective international cohort study in which men from Brazil, the United States, and Mexico were enrolled. The design and protocols of this study allowed unraveling crucial information regarding the relationship between HPV infection and clinical consequences in men, and associated risk factors at each of the anatomic sites where HPV is known to cause cancer in men.

Understanding the burden of bacterial sexually transmitted infections and Trichomonas vaginalis among black Caribbeans in the United Kingdom: Findings from a systematic review

BACKGROUND

In the UK, people of black Caribbean (BC) ethnicity continue to be disproportionately affected by bacterial sexually transmitted infections (STIs) and Trichomonas vaginalis (TV). We systematically reviewed evidence on the association between bacterial STIs/TV and ethnicity (BC compared to white/white British (WB)) accounting for other risk factors; and differences between these two ethnic groups in the prevalence of risk factors associated with these STIs, sexual healthcare seeking behaviours, and contextual factors influencing STI risk.

METHODS

Studies presenting relevant evidence for participants aged ≥14 years and living in the UK were eligible for inclusion. A pre-defined search strategy informed by the inclusion criteria was developed. Eleven electronic databases were searched from the start date to September-October 2016. Two researchers independently screened articles, extracted data using a standardised proforma and resolved discrepancies in discussion with a third researcher. Descriptive summaries of evidence are presented. Meta-analyses were not conducted due to variation in study designs. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

RESULTS

Of 3815 abstracts identified, 15 articles reporting quantitative data were eligible and included in the review. No qualitative studies examining contextual drivers of STI risk among people of BC ethnicity were identified. Compared to the white/WB ethnic group, the greater STI/TV risk among BCs was partially explained by variations in socio-demographic factors, sexual behaviours, and recreational drug use. The prevalence of reporting early sexual debut (<16 years), concurrency, and multiple partners was higher among BC men compared to white/WB men; however, no such differences were observed for women. People of BC ethnicity were more likely to access sexual health services than those of white/WB ethnicity.

CONCLUSIONS

Further research is needed to explore other drivers of the sustained higher STI/TV prevalence among people of BC ethnicity. Developing holistic, tailored interventions that address STI risk and target people of BC ethnicity, especially men, could enhance STI prevention.

Examining the role of socioeconomic deprivation in ethnic differences in sexually transmitted infection diagnosis rates in England: evidence from surveillance data

Differences by ethnic group in STI diagnosis rates have long been recognized in England. We investigated whether these may be explained by ethnic disparities in socioeconomic deprivation (SED). Data on all diagnoses made in sexual health clinics in England in 2013 were obtained from the mandatory STI surveillance system. Poisson regression was used to calculate incidence rate ratios (IRRs) of STIs, by ethnicity, with and without adjustment for index of multiple deprivation (IMD) a measure of area-level deprivation. Unadjusted IRRs (95% confidence intervals) were highest for gonorrhoea [8·18 (7·77-8·61) and 5·76 (5·28-6·29)] and genital herpes [4·24 (3·99-4·51) and 3·58 (3·23-3·98)] for people of black Caribbean and non-Caribbean/non-African black ethnicity and IRRs were highest for syphilis [8·76 (7·97-9·63)] and genital warts [2·23 (2·17-2·29)] for people of non-British/non-Irish white ethnicity compared to white British ethnicity. After adjustment for IMD, IRRs for gonorrhoea [5·76 (5·47-6·07)] and genital herpes [3·73 (3·50-3·97)] declined but remained highest for black Caribbeans and IRRs for syphilis [7·35 (6·68-8·09)] and genital warts [2·10 (2·04-2·16)] declined but remained highest for non-British/non-Irish white compared to white British. In England, ethnic disparities in STI diagnosis rates are partially explained by SED, but behavioural and contextual factors likely contribute. Clinic and community-based interventions should involve social peer networks to ensure they are targeted and culturally sensitive.

Behavioral and socioeconomic risk factors associated with probable resistance to ceftriaxone and resistance to penicillin and tetracycline in Neisseria gonorrhoeae in Shanghai

Globally, incidence of Neisseria gonorrhoeae infection is once again the highest of the bacterial sexually transmitted infections. The bacterium can produce serious complications in those infected, and emerging resistance to third generation cephalosporins could usher in an era of potentially untreatable gonorrhea. This research aimed to identify risk factors for antibiotic resistant gonorrhea infection among clients at a Shanghai sexually transmitted infection clinic over two time periods, 2004-2005 and 2008-2011. Demographic and risk factor behavior data, and biological samples for antimicrobial resistance analysis, were collected. Statistical models were built to identify risk factors associated with probable resistance to ceftriaxone and resistance to penicillin and tetracycline. High levels of ciprofloxacin resistance (98%) in our sample precluded examining its risk factors; all isolates were susceptible to spectinomycin. Overall (P<0.001), chromosomal (P<0.001), and plasmid-mediated (P = 0.01) penicillin resistance decreased from the first to second period of the study. For tetracycline, chromosomal resistance decreased (P = 0.01) and plasmid-mediated resistance increased (P<0.001) between the first and second periods of study. In multi-level multivariable regression models, male gender (P = 0.03) and older age (P = 0.01) were associated with increased minimum inhibitory concentrations to ceftriaxone. Male gender (P = 0.03) and alcohol use (P = 0.02) were associated with increased odds of overall tetracycline resistance. Male gender was associated with increased odds of chromosomally-mediated tetracycline resistance (P = 0.04), and alcohol use was associated with increased odds of plasmid-mediated tetracycline resistance (P = 0.02). Additionally, individuals in middle-salary categories were found to have lower odds of plasmid-mediated resistance to tetracycline compared with those in the lowest salary category (P≤0.02). This study is one of the first to use multilevel analysis to consider the association between risk factors for gonorrhea infections and mechanisms of resistance to individual antibiotics. Such information is urgently needed to combat the growing threat of untreatable gonorrhea.

Distribution and risk factors of Trichomonas vaginalis infection in England: an epidemiological study using electronic health records from sexually transmitted infection clinics, 2009-2011

We used data from the Genitourinary Medicine Clinic Activity Dataset (GUMCAD) over a 3-year period (2009-2011) to investigate the distribution and risk factors of Trichomonas vaginalis infection in England. Socio-demographic and clinical risk factors associated with a diagnosis of T. vaginalis were explored using multivariable logistic regression. Rates of T. vaginalis infection were highest in London and the West Midlands. For men and women, T. vaginalis infection was significantly associated with: older age compared to those aged 20-24 years, non-white ethnicity (in particular black Caribbean and black 'other' ethnic groups), and birth in the Caribbean vs. birth in the UK. Current gonorrhoea or chlamydia infection was associated with a diagnosis of T. vaginalis in women. Further research is required to assess the public health impact and cost-effectiveness of introducing targeted screening for women at high risk of infection in areas of higher prevalence.

Declining genital Warts in young women in england associated with HPV 16/18 vaccination: an ecological study

Background. Diagnoses of genital warts (GW) in genitourinary medicine (GUM) clinics have been increasing in England for many years. In 2008, an HPV immunization program began with a bivalent vaccine (Cervarix). This was expected to markedly reduce infections and disease due to human papillomavirus (HPV) 16/18 but not HPV 6/11 infections or disease. However, from 2009 to 2011 there were decreases in reported diagnoses of GW in young females at GUM clinics.

Methods. Using data from GUM clinics and a sample of general practices (GPs) throughout England, we analyzed rates of GW diagnoses by age, year of diagnosis, and estimated immunization coverage.

Results. The overall reduction in GW diagnoses at GUM clinics between 2008 and 2011 was 13.3% among 16- to 19-year-old females, with the greatest decline of 20.8% in 17-year-olds. Declines were positively associated with estimated immunization coverage. A similar pattern was seen in GP diagnoses, but not among older women, and for other GUM consultations.

Conclusions. Several factors might contribute to declines in GW. However, the size and pattern of the declines strongly suggest that we are observing an unexpected, moderately protective effect of HPV 16/18 vaccination against GW.

Comparison of risk factors for prevalent sexually transmitted infections based on attendees at two genitourinary medicine clinics in Ireland

Little has changed in sexually transmitted infection (STI) epidemiology in Ireland since 2000. Three STIs comprise approximately 90% of notifications; ano-genital warts, Chlamydia trachomatis and non-specific urethritis. Our objective was to compare the risk factors for prevalent STIs in attendees at two genitourinary medicine clinics and examine the incidence of coinfection. Diagnostic, demographic and behavioural information on attendees at two clinics in southwest Ireland were collected from January 1999 to July 2009. Risk factors associated with first episodes of ano-genital warts, genital herpes simplex viral infection, non-specific urethritis and C. trachomatis were investigated. In all, 22,705 STI patients (mean age 27 years) received 26,824 diagnoses; 1628 had more than one infection. Ano-genital warts was most likely to be diagnosed with a coinfection. Having multiple partners was positively associated with a diagnosis of bacterial infection but not viral infection. Our large cohort outlines those at risk in the region, showing age and gender influences the risk and type of infection. Smoking, alcohol and drug use is also common, all regarded as markers of risk-taking behaviour. The younger the age, the higher the risk of acquiring infection, regardless of infection type. Prevention strategies that target youth, bacterial STIs and high-risk behaviour, including sexual, alcohol and drugs, may be effective in reducing STI incidence in Ireland.

Prevalence of Trichomonas vaginalis and coinfection with Chlamydia trachomatis and Neisseria gonorrhoeae in the United States as determined by the Aptima Trichomonas vaginalis nucleic acid amplification assay

Our aim was to determine Trichomonas vaginalis prevalence using the Aptima Trichomonas vaginalis assay (ATV; Gen-Probe) and the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae coinfections in U.S. women undergoing screening for C. trachomatis/N. gonorrhoeae. Discarded urogenital samples from 7,593 women (18 to 89 years old) undergoing C. trachomatis/N. gonorrhoeae screening using the Aptima Combo 2 assay (Gen-Probe) in various clinical settings were tested with ATV. Overall, T. vaginalis, C. trachomatis, and N. gonorrhoeae prevalences were 8.7%, 6.7%, and 1.7%, respectively. T. vaginalis was more prevalent than C. trachomatis or N. gonorrhoeae in all age groups except the 18- to 19-year-old group. The highest T. vaginalis prevalence was in women ≥ 40 years old (>11%), while the highest C. trachomatis prevalence (9.2%) and N. gonorrhoeae prevalence (2.2%) were in women <30 years old. Coinfection prevalences were 1.3% for C. trachomatis/T. vaginalis, 0.61% for C. trachomatis/N. gonorrhoeae and N. gonorrhoeae/T. vaginalis, and 0.24% for C. trachomatis/N. gonorrhoeae/T. vaginalis and highest in women <30 years old. T. vaginalis prevalence differed by race/ethnicity, with the highest prevalence in black women (20.2%). T. vaginalis prevalence ranged from 5.4% in family planning clinics to 22.3% in jails. Multivariate analysis determined that ages of ≥ 40 years, black race, and patient locations were significantly associated with T. vaginalis infection. T. vaginalis is the most common sexually transmitted infection (STI) in women of >40 years, while C. trachomatis and N. gonorrhoeae prevalence is lowest in that age group. Higher T. vaginalis prevalence in women of >40 years is probably attributed to the reason for testing, i.e., symptomatic status versus routine screening in younger women. Coinfections were relatively low. High T. vaginalis prevalence in all age groups suggests that women screened for C. trachomatis/N. gonorrhoeae, whether asymptomatic or symptomatic, should be screened for T. vaginalis.

The importance of distinguishing between black Caribbeans and Africans in understanding sexual risk and care-seeking behaviours for sexually transmitted infections: evidence from a large survey of people attending genitourinary medicine clinics in England

BACKGROUND

In the UK, black Caribbean and African populations experience disproportionately high rates of sexually transmitted infections (STIs) and HIV. Often studies do not differentiate between these populations notwithstanding differences in STI epidemiology and sociodemographics.

METHODS

Patterns of care-seeking behaviour for STIs were explored separately for black Caribbean (n = 345), black African (n = 193) and white people through a cross-sectional survey of 2824 people attending five genitourinary medicine (GUM) clinics in England.

RESULTS

Black Caribbean men were least likely to use, or try to use, their general practice surgery prior to GUM clinic attendance (16.6%). Symptomatic black Caribbean and African men were least likely to delay seeking care (30.8 and 26.3%, respectively). Symptomatic black Caribbean men faced the least provider delay in accessing care (27.3%). Black Caribbean men and women were most likely, and black African men and women least likely, to be diagnosed with an STI (49.7 and 32.0% versus 26.8 and 16.3%, respectively). Among symptomatic women, black Caribbeans and, among symptomatic men, black Africans were most likely to report abstaining from sex (46.3 and 73.1%, respectively).

CONCLUSIONS

Our analyses highlight the importance of distinguishing between black ethnic groups and the need for future studies to ensure sufficiently large samples to permit such analyses.

Genital chlamydia, genital herpes, Trichomonas vaginalis and gonorrhea prevalence, and risk factors among nearly 70,000 randomly selected women in 4 Nordic countries

BACKGROUND

The aim of this study was to assess the prevalence of women reporting ever having genital chlamydia, genital herpes, Trichomonas vaginalis, and gonorrhea, and to identify factors associated with each of these sexually transmitted infections (STIs).

METHODS

The study was based on a large cross-sectional survey conducted in 2004-2005 among randomly sampled women (18-45 years) from the computerized population registries in Denmark, Iceland, Norway, and Sweden. A total of 69,567 women were included in the study.

RESULTS

The overall prevalence in Denmark, Iceland, Norway, and Sweden was 1.5% for reporting ever having had Trichomonas vaginalis, 1.9% for gonorrhea, 4.8% for genital herpes, and 17.0% for genital chlamydia. The prevalence of each of these STIs varied with birth cohort and country. In addition, they were strongly associated with lifetime number of partners and having a previous diagnosis of another sexually transmitted infection. Moreover, a diagnosis of genital chlamydia or gonorrhea was associated with early age at first intercourse and smoking initiation. Finally, reporting genital chlamydia was associated with early age at drinking initiation, and ever use of hormonal contraceptives and condoms.

CONCLUSION

Genital chlamydia occurs frequently among women in the Nordic countries. Risk-taking behavior, particularly sexual behavior, is strongly associated with STIs, which suggest that further information is needed about STIs and their consequences, targeting high-risk groups. There is also a need for continued monitoring of STIs in order to follow the prevalence and to gain further knowledge about risk factors.

Risk factors for incident condyloma in a multinational cohort of men: the HIM study

Identifying factors associated with condyloma are necessary for prevention efforts. Risk factors for incident condyloma were examined in a cohort of 2487 men from the United States, Brazil, and Mexico and were followed up every 6 months (median, 17.9 months). Factors strongly associated with condyloma were incident infection with human papillomavirus (HPV) types 6 and 11 (hazard ratio [HR], 12.42 [95% confidence interval {CI}, 3.78-40.77]), age (HR, 0.43 [95% CI, .26-.77]; 45-70 vs 18-30 years), high lifetime number of female partners (HR, 5.69 [95% CI, 1.80-17.97]; ≥21 vs 0 partners), and number of male partners (HR, 4.53 [95% CI, 1.68-12.20]; ≥3 vs 0 partners). The results suggest that HPV types 6 and 11 and recent sexual behavior are strongly associated with incident condyloma.

Genital HPV infection and related lesions in men

Human papillomavirus (HPV) is highly prevalent in men and there is an interest in further understanding the relationship between HPV infection and disease in men, including the development of genital warts, penile intraepithelial neoplasia and invasive penile carcinomas. Genital warts are caused by HPV 6/11 and are the most common clinical manifestation of HPV in men. Though they are benign and not associated with mortality, they are a source of psychosocial distress and physical discomfort. HPV infection can also develop into invasive penile carcinoma which is associated with morbidity and mortality. Approximately 40% of invasive penile carcinomas are attributable to HPV with HPV 16, 18, and 6/11 being the genotypes most commonly detected in penile tumors. Penile carcinomas of the basaloid and warty histologic subtypes are most likely to test positive for HPV. In addition to HPV infection, the risk factors most strongly associated with penile cancer are lack of neonatal circumcision, phimosis (the inability of uncircumcised men to fully retract the foreskin), and anogenital warts. Male vaccination with the quadrivalent HPV vaccine that protects against HPV 6/11/16/18 has been shown to significantly reduce HPV-associated anogenital infection and disease in men. If the quadrivalent vaccine is successfully disseminated to large segments of the young male population, there is the potential for substantial reduction in genital HPV infection and related lesions in men.

Sexual risk behaviours and sexual health outcomes among heterosexual black Caribbeans: comparing sexually transmitted infection clinic attendees and national probability survey respondents

We compared sociodemographic characteristics, sexual risk behaviours and sexual health experiences of 266 heterosexual black Caribbeans recruited at a London sexual health clinic between September 2005 and January 2006 with 402 heterosexual black Caribbeans interviewed for a British probability survey between May 1999 and August 2001. Male clinic attendees were more likely than men in the national survey to report: ≥10 sexual partners (lifetime; adjusted odds ratio [AOR]: 3.27, 95% confidence interval [CI]: 1.66-6.42), ≥2 partners (last year; AOR: 5.40, 95% CI: 2.64-11.0), concurrent partnerships (AOR: 3.26, 95% CI: 1.61-6.60), sex with partner(s) from the Caribbean (last 5 years; AOR: 7.97, 95% CI: 2.42-26.2) and previous sexually transmitted infection (STI) diagnosis/diagnoses (last 5 years; AOR: 16.2, 95% CI: 8.04-32.6). Similar patterns were observed for women clinic attendees, who also had increased odds of termination of pregnancy (AOR: 3.25, 95% CI: 1.87-5.66). These results highlight the substantially higher levels of several high-risk sexual behaviours among UK black Caribbeans attending a sexual health clinic compared with those in the general population. High-risk individuals are under-represented in probability samples, and it is therefore important that convenience samples of high-risk individuals are performed in conjunction with nationally representative surveys to fully understand the risk behaviours and sexual health-care needs of ethnic minority communities.

Fishermen as a Suitable Population for HIV Intervention Trials

Background. Suitable populations to sustain continued evaluation of HIV and sexually transmitted infection (STI) prevention interventions are required. We sought to determine whether fishermen are a suitable population for HIV intervention trials. Methods. In a cross-sectional descriptive survey, we selected 250 fishermen from proportional to size sampled boats. We collected socioeconomic and behavioral information, and specimens for HIV, herpes simplex virus (HSV-2), syphilis, gonorrhea, chlamydia and human papillomavirus (HPV) tests from consenting participants. Results. One third of the fishermen had concurrent sexual partnerships and two thirds were involved in transactional sex. About 70% were involved in extramarital sex with only one quarter using condoms in their three most recent sexual encounters. HIV prevalence was 26% and HSV-2 and HPV was 57%. Over 98% were willing to participate in a future HIV prevention clinical trial. Conclusion. Fishermen are a high-risk group for HIV/STI infections that may be suitable for HIV prevention trials. A cohort study would be useful to measure the incidence of HIV/STIs to ultimately determine the feasibility of enrolling this population in an HIV/STI prevention clinical trial.

Destigmatizing genitourinary medicine and sexually transmitted infections in the UK

Sexually transmitted infections (STIs) and the clinics patients attend for STI management remain stigmatized. Although emphasizing sexual intercourse rather than sexual behaviour as an important factor in STI acquisition may help to destigmatize STIs, this will require a change in the national mindset. A different approach entails destigmatizing genitourinary (GU) medicine/sexual health thereby normalizing the conditions managed in these settings. This may be helped by emphasizing the non-STI-related aspect of GU medicine and by considering a change in terminology that removes the focus from STIs and attempts to absorb the term into the broader category of genital infection.

Increased sexually transmitted infection incidence in a low risk population: identifying the risk factors

BACKGROUND

Between 1994 and 2006, the incidence of sexually transmitted infections (STIs) in Ireland has increased by over 300%. Recent literature would suggest that this figure is an underestimation of the true scale of infection. Our objective was to determine the risk factors associated with STI diagnosis in a population with a rapidly increasing STI incidence.

METHODS

Using diagnostic, demographic and behavioural information from three STI clinics (January 1999 to December 2006), multivariable logistic regression models were used to identify risk factors associated with STI diagnosis.

RESULTS

Age, smoking and inconsistent condom use are the dominant risk factors. Males aged 20-24 years and females aged <20 years being at greatest risk of STI acquisition. Having three or more partners was not associated with an elevated risk of STI diagnosis. At univariate level, homosexuals and bisexuals have a decreased risk of STI acquisition compared with heterosexuals. Rate of consistent condom use was low < or =13.3%.

CONCLUSIONS

Age, condom use and number of sexual partners are important risk factors for STI diagnosis. Contrary to international STI literature, having multiple sexual partners does not increase STI incidence. Age specific behavioural interventions that target increased condom use may be effective in reducing STIs in Ireland. At policy level, a reduction in the taxation on condoms from 13.5 to 5% is needed to lower the prohibitive cost and increase their use.

Prevalence and risk factors of the whole spectrum of sexually transmitted diseases in male incoming prisoners in France

Sexually transmitted diseases (STD) are a public health issue in prison. As inmates are eventually released, it is also a community concern. There are very few data on the entire spectrum of STDs, particularly condyloma among prisoners. To determine the prevalence of all STDs: infection with human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), herpes simplex virus (HSV), Chlamydia trachomatis, Neisseria gonorrhoea, syphilis, and condyloma among entering inmates. A cross-sectional study was conducted in France from November 2000 to June 2003. Male adults entering a prison remand center in Caen had a medical consultation and physical examination including external genital organs and perianal area for condyloma and herpes infection, a urethral swab for Chlamydia trachomatis and Neisseria gonorrhoea detection, and a blood sample for HBV, HCV, HIV, and syphilis serology. Five hundred and ninety-seven inmates agreed to participate in the study. Sixteen percent had at least one STD: 4.0% had condyloma, 4.0% chlamydia infection, and 4.9% were positive for HCV antibodies. Two had early syphilis and 1 had acute HBV, but no HIV infection, neither genital herpes nor gonorrhea. The analysis of the STD risk behaviors did not show any difference between the infected and uninfected participants, except that HCV-positive participants were more likely to be intravenous drug users. Results suggest that a systematic screening of all STDs should be at least proposed to every entering inmate since no demographic or sexual characteristics are consistently associated with STDs.

The case for social marketing in gonorrhoea prevention: insights from sexual lifestyles in Glasgow genitourinary medicine clinic attendees

We conducted a matched case-control study to investigate social factors associated with gonorrhoea acquisition among genitourinary (GU) medicine clinic attendees, designed to inform appropriate prevention strategies. Detailed social and behavioural data were elicited using a self-completed questionnaire. The effect sizes of these characteristics were quantified using univariate and multivariable conditional logistic regression in 53 cases and 106 matched controls. Homo-bisexual orientation was the strongest independent predictor of gonorrhoea acquisition (Adjusted odds ratio 31.1 (95% confidence intervals, 3.09-312.92). Other independent predictors were not currently being in a relationship and concordant residential characteristics. Three principal implications for sexual health policy were identified; social marketing approaches to gonorrhoea prevention should focus on gay men and individuals not in established relationships; gonorrhoea prevention should be more closely integrated with wider social inclusion policies; finally, more proactive, systematic and theory-based approaches should capitalize on opportunities for sexual health promotion in GU medicine clinic settings.

Patients’ reasons for attending the genitourinary medicine clinic

Summary:

Patients’ reasons for attending the genitourinary medicine clinic inform and dictate the range of provisions and advice that the staff should provide. The objective analysis of these reasons would better inform the process of triage, clinical services and contractual arrangements (e.g. new to follow-up ratios). Our findings indicate that almost one in every two patients is presenting first with genitourinary symptoms and the majority of the remainder either identified themselves to be at risk or were identified by the attending clinician as having medical concerns and/or risk factors. This patient group could benefit, and must be offered, tests to exclude all sexually transmitted infections (within the condition's own incubation/test window periods).

'People make assumptions about our communities': sexual health amongst teenagers from black and minority ethnic backgrounds in East london

OBJECTIVES

(1) To explore sexual behaviour and relationships amongst Black and minority ethnic (BME) teenagers in East London. (2) To examine how these relationships are shaped by culture, gender, peer norms and religion. (3) To describe the implications for sexual health policy and practice in urban, multicultural areas.

DESIGN

This report draws primarily on the qualitative arm of a mixed methods study which collected data from 126 young people, aged 15-18, largely through focus groups in the London boroughs of Hackney, Newham and Tower Hamlets.

RESULTS

Previous research has reported culture influencing the patterning of risk/protection amongst BME groups. Our data suggest that this is mediated by gender, religion and youth. Religion reportedly influenced young women's sexual behaviour in multiple ways. Young people described gendered norms in meeting and flirting with partners, and the role of mobile phones and peer pressure.

CONCLUSION

Our paper suggests culture, gender, religion and youth influence BME teenagers in aspects of sexual relationships, and that these social markers may have different contextual meanings for individuals. The multiplicity of factors affecting attitudes/behaviour requires a range of contraceptive, counselling, screening and sex education services available for all teenagers, although delivery patterns may differ in response to differing needs.

Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study

OBJECTIVE

The objective of this study was to determine the prevalence, incidence, and risk factors for genital and anal warts in HIV-negative homosexual men in Sydney.

STUDY DESIGN

The authors conducted a prospective cohort study. Participants were asked whether they had had genital and anal warts at each interview. Details of lifetime sexual contacts and sexual behaviors in the last 6 months were collected.

RESULTS

Among 1,427 men recruited, 8.9% and 19.6% reported a history of genital and anal warts at baseline, respectively. Incidence rates for genital and anal warts were 0.94 and 1.92 per 100 person-years, respectively. In multivariate analysis, both incident genital and anal warts were associated with younger age. In addition, incident genital warts was associated with insertive fingering (P trend = 0.018), whereas incident anal warts was associated with insertive fingering (P trend = 0.007) and insertive fisting (P trend = 0.039).

CONCLUSIONS

Anal warts were twice as common as genital warts. Fingering and other manual sexual practices may be an important transmission route for both.

What can be gained from comprehensive disaggregate surveillance? The Avon Surveillance System for Sexually Transmitted Infections

OBJECTIVE

To describe a new disaggregate surveillance system covering key diagnosed sexually transmitted infections in a UK locality.

METHODS

The Avon System for Surveillance of Sexually Transmitted Infections (ASSIST) collects computerised person- and episode-based information about laboratory-diagnosed sexually transmitted infections from genitourinary medicine (GUM) clinics, the Avon Brook Clinic, and the Health Protection Agency and trust laboratories in primary care trusts in Avon. The features of the system are illustrated here, by describing chlamydia-testing patterns according to the source of test, age and sex, and by mapping the distribution of chlamydia across Bristol, UK.

RESULTS

Between 2000 and 2004, there were 821,685 records of tests for sexually transmitted infections, with 23,542 positive results. The proportion of tests and positive results for chlamydia and gonorrhoea sent from general practice increased over time. Most chlamydia tests in both GUM and non-specialist settings were performed on women aged >25 years, but positivity rates were highest in women aged <25 years. The positivity rate remained stable between 2000 and 2004. Including data from all diagnostic settings, chlamydia rates were about twice as high as those estimated only from genitourinary clinic cases.

CONCLUSIONS

The ASSIST model could be a promising new tool for planning and measuring sexual health services in England if it can become sustainable and provide more timely data using fewer resources. Collecting denominator data and including infections diagnosed in primary care are essential for meaningful surveillance.

Determinants of genital wart case detection rates among STD clinic attendees in Athens, Greece

BACKGROUND AND OBJECTIVE

To report significant sociodemographic and behavioral outpatient characteristics associated with the diagnosis of genital warts.

METHODS

Cross-sectional hospital-based study (1990-96).

RESULTS

Genital warts (n = 2988, 51.2%) represent the leading sexually transmitted disease (STD) among 5831 consecutive symptomatic Greek and foreign immigrant STD outpatients. In Greek heterosexuals a low rate of partner change was the main patient characteristic at diagnosis (median: one partner in the past 6 months). Lower detection rate and riskier behavior characterized immigrants. Although associated with risky behavior, homo/bisexual orientation in males and injecting drug use were not significantly associated with condyloma diagnosis in the context of STDs.

CONCLUSION

Broader health education and secondary prevention are needed to control this infection, whereas low-risk behavior in Greek heterosexuals with condylomata facilitates further preventive interventions.

Epidemiology of HIV among black and minority ethnic men who have sex with men in England and Wales

OBJECTIVES

To examine the epidemiology of HIV among black and minority ethnic (BME) men who have sex with men (MSM) in England and Wales (E&W).

METHODS

Ethnicity data from two national HIV/AIDS surveillance systems were reviewed (1997-2002 inclusive), providing information on new HIV diagnoses and those accessing NHS HIV treatment and care services. In addition, undiagnosed HIV prevalence among MSM attending 14 genitourinary medicine (GUM) clinics participating in the Unlinked Anonymous Prevalence Monitoring Programme and having routine syphilis serology was examined by world region of birth.

RESULTS

Between 1997 and 2002, 1040 BME MSM were newly diagnosed with HIV in E&W, representing 12% of all new diagnoses reported among MSM. Of the 1040 BME MSM, 27% were black Caribbean, 12% black African, 10% black other, 8% Indian/Pakistani/Bangladeshi, and 44% other/mixed. Where reported (n = 395), 58% of BME MSM were probably infected in the United Kingdom. An estimated 7.4% (approximate 95% CI: 4.4% to 12.5%) of BME MSM aged 16-44 in E&W were living with diagnosed HIV in 2002 compared with 3.2% (approximate 95% CI: 2.6% to 3.9%) of white MSM (p<0.001). Of Caribbean born MSM attending GUM clinics between 1997 and 2002, the proportion with undiagnosed HIV infection was 15.8% (95% CI: 11.7% to 20.8%), while among MSM born in other regions it remained below 6.0%.

CONCLUSIONS

Between 1997-2002, BME MSM accounted for just over one in 10 new HIV diagnoses among MSM in E & W; more than half probably acquired their infection in the United Kingdom. In 2002, the proportion of BME MSM living with diagnosed HIV in E&W was significantly higher than white MSM. Undiagnosed HIV prevalence in Caribbean born MSM was high. These data confirm the need to remain alert to the sexual health needs and evolving epidemiology of HIV among BME MSM in E&W.

The interrelation of demographic and geospatial risk factors between four common sexually transmitted diseases

OBJECTIVES

To examine the interrelation between demographic and geospatial risk factors for gonorrhoea, chlamydia, genital warts, and genital herpes.

DESIGN

We analysed age, sex, ethnicity, socioeconomic status, and area of residence for Leeds residents aged 15-54 with Neisseria gonorrhoeae, genital Chlamydia trachomatis, first episode genital herpes, and first episode genital warts during 1994-5. The 1991 UK census provided denominator population information.

RESULTS

Regression analysis showed that young age (15-24 years), ethnicity (with a gradient of risk black >white >Asian), and residence in inner city areas of deprivation were independent risk factors for all STDs. There were highly significant correlations in the geospatial distribution of incidence rates between the four infections. However, there was variation in the degree of central urban clustering, with gonorrhoea having the most restricted, and genital warts and chlamydia the widest distribution. 31% of all disease occurred in the four inner city census wards, representing 15% of the population.

CONCLUSION

These results are in keeping with core group theory applying in a unified manner to the four most common UK sexually transmitted diseases in this urban area. Population based studies are needed to clarify whether ethnicity is associated with differing sexual behavioural or mixing patterns. Our data suggest that chlamydia screening in women <25 years of age could detect 70% of cases in the community, that such programmes should give particular emphasis to implementation in core group areas, and that they could function as unifying strategies for the control of most common STDs within urban areas.

Rate and predictors of new genital warts claims and genital warts-related healthcare utilization among privately insured patients in the United States

BACKGROUND

Little non-clinic-based data are available on incident genital warts rates and related healthcare use.

GOAL

: The goal of this study was to describe the incidence and predictors of genital warts and associated healthcare utilization patterns among a group of privately insured patients in the United States.

STUDY

Health claims were evaluated prospectively from 5,914,107 privately insured individuals.

RESULTS

The rate of new genital warts claims per 100,000 person-years at risk, age-standardized to the 2001 U.S. privately insured population, increased from 117.8 in 1998 to 205.0 in 2001. The highest rates were among 20- to 29-year-olds. The majority of claims came from dermatology and obstetrics/gynecology.

CONCLUSIONS

The incidence of genital warts, as measured by the rate of new claims, appears to be rising. Age associations with the rate of new genital warts claims differed by gender; these associations may be influenced by changes in health-seeking behavior, potentially driven by health awareness.

Black Caribbean adults with HIV in England, Wales, and Northern Ireland: an emerging epidemic?

BACKGROUND

HIV is now well established in the Caribbean, with prevalence in several countries being surpassed only by those of sub-Saharan Africa. Continuing inward migration from the Caribbean and a high incidence of some bacterial STIs among Britain's black Caribbean communities, suggests a considerable potential for HIV spread.

METHODS

Data from three national HIV/AIDS surveillance systems were reviewed, providing information on new HIV diagnoses, numbers accessing treatment and care services, and HIV prevalence.

RESULTS

Between 1997 and 2001, 528 black Caribbean adults were newly diagnosed with HIV; 62 new diagnoses in 1997, rising to 176 in 2001. Probable heterosexual acquisition accounted for 335 (63%) infections (161 (48%) males, 174 females), and sex between men 171 (32%). Infection was acquired both in the Caribbean and in the United Kingdom. Numbers of black Caribbeans accessing treatment and care services more than doubled between 1997 (294) and 2001 (691). In 2001, 528 (76%) black Caribbeans accessing services were London residents. Among the Caribbean born previously undiagnosed heterosexuals, HIV prevalence was 0.7%; among men who have sex with men (MSM) it was 10.4%. Of those born in the Caribbean, 73% of male heterosexuals, 50% of female heterosexuals, and 65% of MSM who were previously undiagnosed left the clinic unaware of their HIV infection.

CONCLUSIONS

Numbers of black Caribbean adults newly diagnosed and accessing treatment and care services in England, Wales, and Northern Ireland increased between 1997 and 2001. Despite a high prevalence of diagnosed bacterial STIs, prevalence among Caribbean born heterosexuals remains low, but it is high among MSM. Surveillance data highlight the need for targeted HIV prevention among black Caribbeans.

Doing the analysis differently. Using narrative to inform understanding of patient participation in contact tracing for sexually transmissible infections

The aims and objectives of this paper were to understand the key influences hindering patients, participation in the contact tracing process for sexually transmissible infection exposure; to study the anatomy of acomplex sexual network through the eyes of a committed contact tracer and a group of teenagers; and to identify lessons from the research. Unstructured and group interviews were undertaken with a group of sixth form students and an unstructured interview with a contact tracer. Cue (storyboards) cards and hypothetical sexual networks were used--the outcome demonstrated that generated narrative about sexual network experiences can be analysed using a schema of representation of experience and could be subjected to Labov's structural categories for assignment of spheres of action, to undertake interpretation. Themes identified include: confidentiality, secrecy, friendship, community, the law and social sanctions. We conclude that contact tracing is under the spotlight and that we need to understand the personal experiences of being subjected to a process where little consideration has been given to the social and psychological consequences. Narrative analytic strategies can be applied to gain this much-needed rich data.

Re-emerging syphilis: a detrended correspondence analysis of the behaviour of HIV positive and negative gay men

Background

Recent syphilis outbreaks in the UK have raised serious concerns about the sexual health of the population. Moreover, syphilis appears more likely to facilitate HIV transmission than any other sexually transmitted infection (STI).

Methods

The sexual and other risk behaviour of a sample of HIV positive and negative gay men with and without syphilis was subjected to a detrended correspondence analysis (DCA).

Results

A DCA plot was used to illustrate similarity of individuals in terms of their behaviours, regardless of their infection status. The majority of those with syphilis (78%; 18/23) fell into a high-risk group with more partners, and use of anonymous sex venues and drugs during sex. However, 16% of uninfected controls (8/49) and 62% of HIV positive individuals without syphilis (8/13) also fell into this high-risk group.

Conclusions

Using a statistical technique that is novel for this type of investigation, we demonstrate behavioural overlaps between syphilis-infected individuals in an ongoing UK outbreak and uninfected HIV positive and negative controls. Given the high-risk behaviour of a significant proportion of uninfected individuals, ongoing transmission of syphilis and HIV in this population seems likely.

Behavioural surveillance: the value of national coordination

Behavioural surveillance programmes have enabled the description of population patterns of risk behaviours for STI and HIV transmission and aid in the understanding of how epidemics of STI are generated. They have been instrumental in helping to refine public health interventions and inform the targeting of sexual health promotion and disease control strategies. The formalization and coordination of behavioural surveillance in England and Wales could optimise our ability to measure the impact of interventions and health promotion strategies on behaviour. This will be particularly useful for monitoring the progress towards specific disease control targets set in the Department of Health's new Sexual Health and HIV Strategy.

Characteristics of those who repeatedly acquire sexually transmitted infections: a retrospective cohort study of attendees at three urban sexually transmitted disease clinics in England

BACKGROUND

Individuals who repeatedly acquire sexually transmitted infections (STIs) may facilitate the persistence of disease at endemic levels. Identifying those most likely to become reinfected with an STI would help in the development of targeted interventions.

GOAL

To investigate the demographic and behavior characteristics of sexually transmitted disease (STD) clinic patients most likely to reattend with an STI.

STUDY DESIGN

The proportion of patients attending three STD clinics in England between 1994 and 1998 who reattended for treatment of acute STI within 1 year was estimated from Kaplan-Meier failure curves. A Cox proportional hazard model was used to investigate the relation between rate of reattendance with an acute STI and patient characteristics.

RESULTS

Of the 17,466 patients presenting at an STD clinic with an acute STI, 14% reattended for treatment of an STI within 1 year. Important determinants of reinfection were age, sexual orientation, and ethnicity: 20% of 12- to 15-year-old females (adjusted hazard ratio [HR], 1.90; CI, 1.13-3.18, compared with 20- to 24-year-old females), 22% of homosexual men (adjusted HR, 1.30; CI, 1.07-1.58, compared with heterosexual men), and 25% of black Caribbean attendees (adjusted HR, 1.87; CI, 1.63-2.13, compared with whites) reattended for treatment of acute STI within 1 year. In addition, 21% of those with a history of STI (adjusted HR, 1.42; CI, 1.28-1.59, compared with those with no history of STI) and 17% of individuals reporting three or more partners in the recent past (adjusted HR, 1.53; CI, 1.34-1.73, compared with those with one partner) reattended for treatment of an acute STI within 1 year.

CONCLUSIONS

In this STD clinic population, teenage females, homosexual men, black Caribbean attendees, individuals with a history of STI, and those reporting high rates of sexual partner change repeatedly re-presented with acute STIs. Directing enhanced STD clinic-based interventions at these groups may be an effective strategy for STI control.