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1.  Genital Chlamydia Prevalence in Europe and Non-European High Income Countries: Systematic Review and Meta-Analysis 
PLoS ONE  2015;10(1):e0115753.
Accurate information about the prevalence of Chlamydia trachomatis is needed to assess national prevention and control measures.
We systematically reviewed population-based cross-sectional studies that estimated chlamydia prevalence in European Union/European Economic Area (EU/EEA) Member States and non-European high income countries from January 1990 to August 2012. We examined results in forest plots, explored heterogeneity using the I2 statistic, and conducted random effects meta-analysis if appropriate. Meta-regression was used to examine the relationship between study characteristics and chlamydia prevalence estimates.
We included 25 population-based studies from 11 EU/EEA countries and 14 studies from five other high income countries. Four EU/EEA Member States reported on nationally representative surveys of sexually experienced adults aged 18–26 years (response rates 52–71%). In women, chlamydia point prevalence estimates ranged from 3.0–5.3%; the pooled average of these estimates was 3.6% (95% CI 2.4, 4.8, I2 0%). In men, estimates ranged from 2.4–7.3% (pooled average 3.5%; 95% CI 1.9, 5.2, I2 27%). Estimates in EU/EEA Member States were statistically consistent with those in other high income countries (I2 0% for women, 6% for men). There was statistical evidence of an association between survey response rate and estimated chlamydia prevalence; estimates were higher in surveys with lower response rates, (p = 0.003 in women, 0.018 in men).
Population-based surveys that estimate chlamydia prevalence are at risk of participation bias owing to low response rates. Estimates obtained in nationally representative samples of the general population of EU/EEA Member States are similar to estimates from other high income countries.
PMCID: PMC4304822  PMID: 25615574
2.  Behavioral Convergence: Implications for Mathematical Models of Sexually Transmitted Infection Transmission 
The Journal of Infectious Diseases  2014;210(Suppl 2):S600-S604.
Recent trends in the behaviors of some groups with high sexual activity and of the general population in some countries suggest that sexual behavior profiles of high and low sexual activity categories may be converging and may call into question the assumptions around sexual mixing that are built into theoretical models of sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) transmission dynamics. One category of high sexual activity, sex work, has been undergoing modification in many societies, becoming more acceptable, more dispersed, and larger in volume in some societies and shrinking in others. Concurrent with changes in the characteristics of sex work, the accumulating data on the sexual behaviors of the general population suggest a shift toward those of sex workers, including large numbers of sex partners and short-duration partnerships. The closing of the gap between behaviors associated with high and low sexual activity may have important implications for theories of sexual structure and models of transmission dynamics for STIs, including HIV infection.
PMCID: PMC4231640  PMID: 25381381
sex work; mathematical models; sexually transmitted infections; sexual behavior
3.  Circular Labor Migration and HIV in India: Exploring Heterogeneity in Bridge Populations Connecting Areas of High and Low HIV Infection Prevalence 
The Journal of Infectious Diseases  2014;210(Suppl 2):S556-S561.
Background. The emerging human immunodeficiency virus (HIV) epidemics in rural areas of India are hypothesized to be linked to circular migrants who are introducing HIV from destination areas were the prevalence of HIV infection is higher. We explore the heterogeneity in potential roles of circular migrants in driving an HIV epidemic in a rural area in north India and examine the characteristics of the “sustaining bridge population”, which comprises individuals at risk of HIV acquisition at destination and of HIV transmission into networks at origin capable of sustaining an epidemic.
Methods. Results of a behavioral survey of 639 male migrants from Azamgarh district, India, were analyzed using χ2 tests and logistic regression.
Results. We estimated the size of various subgroups defined by specific sexual behaviors across different locations and over time. Only 20% fit our definition of a sustaining bridge population, with the majority making no apparent contribution to geographical connectedness between high- and low-prevalence areas. However, we found evidence of sexual contacts at origin that could potentially sustain an epidemic once HIV is introduced. Variables associated with sustaining bridge population membership were self-perceived HIV risk, current migrant status, and age.
Conclusions. Circular migrants represent a heterogeneous population in terms of their role as a bridge group. Self-perception of heightened risk could be exploited in designing prevention programs.
PMCID: PMC4231641  PMID: 25381375
geographical connectedness; transients and migrants; HIV infections/epidemiology; India; risk factors; sexual behavior
4.  Developing a Conceptual Framework of Seroadaptive Behaviors in HIV-Diagnosed Men Who Have Sex With Men 
The Journal of Infectious Diseases  2014;210(Suppl 2):S586-S593.
Background. Seroadaptive behaviors are strategies employed by men who have sex with men (MSM) to reduce the transmission risk for human immunodeficiency virus (HIV). It has been suggested that they contribute to the increasing diagnoses of sexually transmitted infections in HIV-diagnosed MSM. To understand the context in which the reemerging sexually transmitted infections appear, we developed a social epidemiological model incorporating the multiple factors influencing seroadaptive behaviors.
Methods. A literature review of seroadaptive behaviors in HIV-diagnosed MSM was conducted. The literature was synthesized using a social epidemiological perspective.
Results. Seroadaptive behaviors are adopted by MSM in high-income countries and are a way for HIV-diagnosed men to manage and enjoy their sexual lives. Influences are apparent at structural, community, interpersonal, and intrapersonal levels. There is little evidence of whether and when the behavior forms part of a premeditated strategy; it seems dependent on the social context and on time since HIV diagnosis. Social rules of HIV disclosure and perception of risk depend on the setting where partners are encountered.
Conclusions. Seroadaptive behaviors are strongly context dependent and can reduce or increase transmission risk for different infectious diseases. Further data collection and mathematical modeling can help us explore the specific conditions in more detail.
PMCID: PMC4231642  PMID: 25381379
HIV; men who have sex with men; seroadaptive
5.  Heterogeneity in Risk of Pelvic Inflammatory Diseases After Chlamydia Infection: A Population-Based Study in Manitoba, Canada 
The Journal of Infectious Diseases  2014;210(Suppl 2):S549-S555.
Background. The association between chlamydia infection and pelvic inflammatory disease (PID) is a key parameter for models evaluating the impact of chlamydia control programs. We quantified this association using a retrospective population-based cohort.
Methods. We used administrative health data sets to construct a retrospective population-based cohort of women and girls aged 12–24 years who were resident in Manitoba, Canada, between 1992 and 1996. We performed survival analysis on a subcohort of individuals who were tested for chlamydia to estimate the risk of PID diagnosed in a primary care, outpatient, or inpatient setting after ≥1 positive chlamydia test.
Results. A total of 73 883 individuals contributed 625 621 person years of follow-up. Those with a diagnosis of chlamydia had an increased risk of PID over their reproductive lifetime compared with those who tested negative (adjusted hazard ratio [AHR], 1.55; 95% confidence interval [CI], 1.43–1.70). This risk increased with each subsequent infection: the AHR was 1.17 for first reinfection (95% CI, 1.06–1.30) and 1.35 for the second (95% CI, 1.04–1.75). The increased risk of PID from reinfection was highest in younger individuals (AHR, 4.55 (95% CI, 3.59–5.78) in individuals aged 12–15 years at the time of their second reinfection, compared with individuals older than 30 years).
Conclusions. There is heterogeneity in the risk of PID after a chlamydia infection. Describing the progression to PID in mathematical models as an average rate may be an oversimplification; more accurate estimates of the cost-effectiveness of screening may be obtained by using an individual-based measure of risk. Health inequalities may be reduced by targeting health promotion interventions at sexually active girls younger than 16 years and those with a history of chlamydia.
PMCID: PMC4231643  PMID: 25381374
Chlamydia trachomatis; cohort study; pelvic inflammatory disease; retrospective study; epidemiology; mathematical models; cost effectiveness
6.  Risk Pathways for Gonorrhea Acquisition in Sex Workers: Can We Distinguish Confounding From an Exposure Effect Using A Priori Hypotheses? 
The Journal of Infectious Diseases  2014;210(Suppl 2):S579-S585.
The population distribution of sexually transmitted infections (STIs) varies broadly across settings. Although there have been many studies aiming to define subgroups at risk of infection that should be a target for prevention interventions by identifying risk factors, questions remain about how these risk factors interact, how their effects jointly influence the risk of acquisition, and their differential importance across populations. Theoretical frameworks describing the interrelationships among risk determinants are useful in directing both the design and analysis of research studies and interventions. In this article, we developed such a framework from a review looking at determinants of risk for STI acquisition, using gonorrhea as an index infection. We also propose an analysis strategy to interpret the associations found to be significant in uniform analyses of observational data. The framework and the hierarchical analysis strategy are of particular relevance in the understanding of risk formation and might prove useful in identifying determinants that are part of the causal pathway and therefore amenable to prevention strategies across populations.
PMCID: PMC4231644  PMID: 25381378
framework; gonorrhea; sex workers; risk of acquisition
7.  The Price of Sex: Condom Use and the Determinants of the Price of Sex Among Female Sex Workers in Eastern Zimbabwe 
The Journal of Infectious Diseases  2014;210(Suppl 2):S569-S578.
Background. Higher prices for unprotected sex threaten the high levels of condom use that contributed to the decline in Zimbabwe's human immunodeficiency virus (HIV) epidemic. To improve understanding of financial pressures competing against safer sex, we explore factors associated with the price of commercial sex in rural eastern Zimbabwe.
Methods. We collected and analyzed cross-sectional data on 311 women, recruited during October–December 2010, who reported that they received payment for their most-recent or second-most-recent sex acts in the past year. Zero-inflated negative binomial models with robust standard errors clustered on female sex worker (FSW) were used to explore social and behavioral determinants of price.
Results. The median price of sex was $10 (interquartile range [IQR], $5–$20) per night and $10 (IQR, $5–$15) per act. Amounts paid in cash and commodities did not differ significantly. At the most-recent sex act, more-educated FSWs received 30%–74% higher payments. Client requests for condom use significantly predicted protected sex (P < .01), but clients paid on average 42.9% more for unprotected sex.
Conclusions. Within a work environment where clients' preferences determine condom use, FSWs effectively use their individual capital to negotiate the terms of condom use. Strengthening FSWs' preferences for protected sex could help maintain high levels of condom use.
PMCID: PMC4231645  PMID: 25381377
female sex work; payments; condom use; sub-Saharan Africa
9.  Partner notification 
Partner notification is an essential part of case management for sexually transmitted infections. Done correctly it reduces persistent or recurrent infection in the index patient, identifies previously undiagnosed infections, and may thus contribute to reduced transmission in the population. The effectiveness of patient referral of partners can be enhanced through the provision of written information and easy access to tests and medication. A recent systematic review of partner notification found that enhanced partner therapy (helping get treatment to partners more rapidly) reduced re-infection in the index case by almost 30% compared with simple patient referral. Provider referral, where the healthcare worker contacts partners directly, can also be effective, and provides an important service for patients who are wary of informing partners themselves. Partner notification services should be available for all patients found to have a sexually transmitted infection, whether the diagnosis is made in specialist settings, or in primary or community-based care. For patients with HIV, partner notification should be addressed when the infection is first diagnosed and revisited for subsequent partners. Access to specialist partner notification services is an important part of any sexual healthcare system. The professional competencies required to undertake partner notification have now been clearly defined.
PMCID: PMC4065334  PMID: 24966787
Contact tracing; HIV prevention and control; HIV transmission; sexual partners; sexually transmitted diseases
10.  Low levels of HIV test coverage in clinical settings in the UK: a systematic review of adherence to 2008 guidelines 
Sexually Transmitted Infections  2014;90(2):119-124.
To quantify the extent to which guideline recommendations for routine testing for HIV are adhered to outside of genitourinary medicine (GUM), sexual health (SH) and antenatal clinics.
A systematic review of published data on testing levels following publication of 2008 guidelines was undertaken. Medline, Embase and conference abstracts were searched according to a predefined protocol. We included studies reporting the number of HIV tests administered in those eligible for guideline recommended testing. We excluded reports of testing in settings with established testing surveillance (GUM/SH and antenatal clinics). A random effects meta-analysis was carried out to summarise level of HIV testing across the studies identified.
Thirty studies were identified, most of which were retrospective studies or audits of testing practice. Results were heterogeneous. The overall pooled estimate of HIV test coverage was 27.2% (95% CI 22.4% to 32%). Test coverage was marginally higher in patients tested in settings where routine testing is recommended (29.5%) than in those with clinical indicator diseases (22.4%). Provider test offer was found to be lower (40.4%) than patient acceptance of testing (71.5%).
Adherence to 2008 national guidelines for HIV testing in the UK is poor outside of GUM/SH and antenatal clinics. Low levels of provider test offer appear to be a major contributor to this. Failure to adhere to testing guidelines is likely to be contributing to late diagnosis with implications for poorer clinical outcomes and continued onwards transmission of HIV. Improved surveillance of HIV testing outside of specialist settings may be useful in increasing adherence testing guidelines.
PMCID: PMC3945742  PMID: 24412996
11.  Inequalities in the care experiences of patients with cancer: analysis of data from the National Cancer Patient Experience Survey 2011–2012 
BMJ Open  2014;4(2):e004567.
To explore inequalities in the care experiences of care by patients clinical or trust-level factors for patients with cancer.
Secondary analysis of data from the National Cancer Patient Experience Survey 2011–2012.
Setting and participants
Adult patients with a primary diagnosis of cancer who attended an acute or specialist National Health Service (NHS) trust in England.
Outcome measure
OR of a patient rating their overall care positively, adjusting for other patient, clinical and trust-level factors.
Using cross-sectional data from 71 793 patients with cancer who completed the National Cancer Patient Experience Survey 2011–2012, we examined associations between patient, clinical and trust-level factors and a summary measure of patient experience, namely overall rating of care. Multivariate logistic regression was used to investigate variation by sociodemographic characteristics adjusting for other patient, clinical and trust-level factors.
Female, non-white and younger patients were less likely to rate their overall care as excellent or very good. Patients with long-standing conditions, particularly those with learning disabilities or mental health conditions, also reported poorer overall care. This variation persisted when other patient, clinical and trust-level factors were controlled for, indicating that there are real differences in experiences among patients with cancer by sociodemographic characteristics.
There is evidence of inequalities in the experiences of patients with cancer in the UK by sociodemographic characteristics such as gender, age, ethnicity and disability. Quality cancer care services must strive to meet the needs of a diverse patient population equally; this study identifies patient groups for whom it appears cancer care services are in greatest need of improvement.
PMCID: PMC3927926  PMID: 24531454
Public Health; Oncology
12.  Determinants and Patterns of Reproductive Success in the Greater Horseshoe Bat during a Population Recovery 
PLoS ONE  2014;9(2):e87199.
An individual's reproductive success will depend on traits that increase access to mates, as well as the number of mates available. In most well-studied mammals, males are the larger sex, and body size often increases success in intra-sexual contests and thus paternity. In comparison, the determinants of male success in species with reversed sexual size dimorphism (RSD) are less well understood. Greater horseshoe bats (Rhinolophus ferrumequinum) exhibit RSD and females appear to exert mate choice when they visit and copulate with males in their underground territories. Here we assessed putative determinants of reproductive success in a colony of greater horseshoe bats during a 19-year period of rapid population growth. We genotyped 1080 bats with up to 40 microsatellite loci and assigned maternity to 99.5% of pups, and paternity to 76.8% of pups. We found that in spite of RSD, paternity success correlated positively with male size, and, consistent with our previous findings, also with age. Female reproductive success, which has not previously been studied in this population, was also age-related and correlated positively with individual heterozygosity, but not with body size. Remarkable male reproductive skew was detected that initially increased steadily with population size, possibly coinciding with the saturation of suitable territories, but then levelled off suggesting an upper limit to a male's number of partners. Our results illustrate that RSD can occur alongside intense male sexual competition, that male breeding success is density-dependent, and that male and female greater horseshoe bats are subject to different selective pressures.
PMCID: PMC3923748  PMID: 24551052
13.  How robust are the natural history parameters used in chlamydia transmission dynamic models? A systematic review 
Transmission dynamic models linked to economic analyses often form part of the decision making process when introducing new chlamydia screening interventions. Outputs from these transmission dynamic models can vary depending on the values of the parameters used to describe the infection. Therefore these values can have an important influence on policy and resource allocation. The risk of progression from infection to pelvic inflammatory disease has been extensively studied but the parameters which govern the transmission dynamics are frequently neglected. We conducted a systematic review of transmission dynamic models linked to economic analyses of chlamydia screening interventions to critically assess the source and variability of the proportion of infections that are asymptomatic, the duration of infection and the transmission probability. We identified nine relevant studies in Pubmed, Embase and the Cochrane database. We found that there is a wide variation in their natural history parameters, including an absolute difference in the proportion of asymptomatic infections of 25% in women and 75% in men, a six-fold difference in the duration of asymptomatic infection and a four-fold difference in the per act transmission probability. We consider that much of this variation can be explained by a lack of consensus in the literature. We found that a significant proportion of parameter values were referenced back to the early chlamydia literature, before the introduction of nucleic acid modes of diagnosis and the widespread testing of asymptomatic individuals. In conclusion, authors should use high quality contemporary evidence to inform their parameter values, clearly document their assumptions and make appropriate use of sensitivity analysis. This will help to make models more transparent and increase their utility to policy makers.
PMCID: PMC3922653  PMID: 24476335
Chlamydia trachomatis; Mathematical modelling; Systematic review; Natural history; Screening
14.  INterpreting the Processes of the UMPIRE Trial (INPUT): protocol for a qualitative process evaluation study of a fixed-dose combination (FDC) strategy to improve adherence to cardiovascular medications 
BMJ Open  2013;3(5):e002313.
This paper describes a planned process evaluation of the Use of a Multidrug Pill In Reducing Cardiovascular Events (UMPIRE) trial, one of several randomised clinical trials taking place globally to assess the potential of cardiovascular drugs as a fixed-dose combination (polypill) in cardiovascular disease prevention. A fixed-dose combination may be a promising strategy for promoting adherence to medication; alleviating pill burden through simplifying regimens and reducing cost. This process evaluation will complement the UMPIRE trial by using qualitative research methods to inform understanding of the complex interplay of factors that underpin trial outcomes.
A series of semistructured, in-depth interviews with local health professionals and UMPIRE trial participants in India and the UK will be undertaken. The aim is to understand their views and experiences of the trial context and of day-to-day use of medications more generally. The grounded theory approach will be used to analyse data and help inform the processes of the UMPIRE trial.
Ethics and dissemination
The study has received ethical approval for all sites in the UK and India where trial participant interviews will be undertaken. The process evaluation will help inform and enhance the understanding of the UMPIRE trial results and its applicability to clinical practice as well as shaping policy regarding strategies for improving cardiovascular medication adherence.
PMCID: PMC3664347  PMID: 23793693
Cardiovascular Disease; Fixed Dose Combination; Medication Adherence; Polypill; Prevention; Process Evaluation
15.  Cotinine versus questionnaire: early-life environmental tobacco smoke exposure and incident asthma 
BMC Pediatrics  2012;12:187.
The use of biomarkers has expanded considerably, as an alternative to questionnaire-based metrics of environmental tobacco smoke (ETS); few studies have assessed the affect of such alternative metrics on diverse respiratory outcomes in children, and we aimed to do so.
We evaluated various measures of birth-year ETS, in association with multiple respiratory endpoints early years of life, in the novel context of a birth cohort at high risk for asthma. We administered questionnaires to parents, both at the end of pregnancy and at one year of life, and measured cotinine in cord blood (CCot; in 275 children) and in urine (UCot; obtained at 12 months in 365 children), each by radioimmunoassay. Multiple logistic regression was used to assess the association of the various metrics with recurrent wheeze at age 2 and with bronchial hyperresponsiveness (BHR) and asthma at age 7.
Self-reported 3rd trimester maternal smoking was associated with significantly increased risk for recurrent wheeze at age 2 (odds ratio 3.5 [95% confidence interval = 1.2,10.7]); the risks associated with CCot and 3rd trimester smoking in any family member were similar (OR 2.9 [1.2,7.0] and 2.6 [1.0,6.5], respectively). No metric of maternal smoking at 12 months appeared to significantly influence the risk of recurrent wheeze at age 2, and no metric of ETS at any time appeared to significantly influence risk of asthma or BHR at age 7.
Biomarker- and questionnaire-based assessment of ETS in early life lead to similar estimates of ETS-associated risk of recurrent wheeze and asthma.
PMCID: PMC3543177  PMID: 23216797
Children; Exposure to environmental tobacco smoke; Bronchial hyperresponsiveness; Wheeze; Asthma
16.  Brief intervention for alcohol misuse in people attending sexual health clinics: study protocol for a randomized controlled trial 
Trials  2012;13:149.
Over the last 30 years the number of people who drink alcohol at harmful levels has increased in many countries. There have also been large increases in rates of sexually transmitted infections. Available evidence suggests that excessive alcohol consumption and poor sexual health may be linked. The prevalence of harmful alcohol use is higher among people attending sexual health clinics than in the general population, and a third of those attending clinics state that alcohol use affects whether they have unprotected sex. Previous research has demonstrated that brief intervention for alcohol misuse in other medical settings can lead to behavioral change, but the clinical- and cost-effectiveness of this intervention on sexual behavior have not been examined.
We will conduct a two parallel-arm, randomized trial. A consecutive sample of people attending three sexual health clinics in London and willing to participate in the study will be screened for excessive alcohol consumption. Participants identified as drinking excessively will then be allocated to either active treatment (Brief Advice and referral for Brief Intervention) or control treatment (a leaflet on healthy living). Randomization will be via an independent and remote telephone randomization service and will be stratified by study clinic. Brief Advice will comprise feedback on the possible health consequences of excessive alcohol consumption, written information about alcohol and the offer of an appointment for further assessment and Brief Intervention. Follow-up data on alcohol use, sexual behavior, health related quality of life and service use will be collected by a researcher masked to allocation status six months later. The primary outcome for the study is mean weekly alcohol consumption during the previous three months, and the main secondary outcome is the proportion of participants who report unprotected sex during this period.
Opportunistic intervention for excessive alcohol use has been shown to be effective in a range of medical settings. The SHEAR study will examine whether delivering such interventions in sexual health clinics results in reductions in alcohol consumption and will explore whether this is associated with changes in sexual behavior.
PMCID: PMC3482149  PMID: 22920408
Alcohol misuse; Intervention; Randomized controlled trial; Sexual health; Effectiveness
17.  Using routine data to monitor inequalities in an acute trust: a retrospective study 
Reducing inequalities is one of the priorities of the National Health Service. However, there is no standard system for monitoring inequalities in the care provided by acute trusts. We explore the feasibility of monitoring inequalities within an acute trust using routine data.
A retrospective study of hospital episode statistics from one acute trust in London over three years (2007 to 2010). Waiting times, length of stay and readmission rates were described for seven common surgical procedures. Inequalities by age, sex, ethnicity and social deprivation were examined using multiple logistic regression, adjusting for the other socio-demographic variables and comorbidities. Sample size calculations were computed to estimate how many years of data would be ideal for this analysis.
This study found that even in a large acute trust, there was not enough power to detect differences between subgroups. There was little evidence of inequalities for the outcome and process measures examined, statistically significant differences by age, sex, ethnicity or deprivation were only found in 11 out of 80 analyses. Bariatric surgery patients who were black African or Caribbean were more likely than white patients to experience a prolonged wait (longer than 64 days, aOR = 2.47, 95% CI: 1.36-4.49). Following a coronary angioplasty, patients from more deprived areas were more likely to have had a prolonged length of stay (aOR = 1.66, 95% CI: 1.25-2.20).
This study found difficulties in using routine data to identify inequalities on a trust level. Little evidence of inequalities in waiting time, length of stay or readmission rates by sex, ethnicity or social deprivation were identified although some differences were identified which warrant further investigation. Even with three years of data from a large trust there was little power to detect inequalities by procedure. Data will therefore need to be pooled from multiple trusts to detect inequalities.
PMCID: PMC3502356  PMID: 22537019
18.  The association between Lymphogranuloma venereum and HIV among men who have sex with men: systematic review and meta-analysis 
Lymphogranuloma venereum (LGV) is an important re-emerging sexually transmitted infection which is reported to affect particularly HIV-positive men who have sex with men (MSM). The aim of this study is to quantify the association between LGV and HIV in the context of the current emergence of LGV.
A systematic review was performed on the emergence of LGV among MSM since 2000. We report the prevalence of HIV infection from descriptive studies of MSM with LGV, and conduct a meta-analysis to produce a summary estimate of the association between LGV and HIV from case-control studies where cases were MSM with LGV and controls were MSM with rectal chlamydia caused by non-LGV serovars.
The prevalence of HIV among LGV cases ranges from 67% to 100% in 13 descriptive studies. There is a significant association between HIV and LGV (odds ratio 8.19, 95% CI 4.68-14.33).
HIV-positive MSM are disproportionately affected by LGV highlighting the importance of prevention efforts to be targeted to this group. Further research is needed to determine whether the association is due to biological or behavioural factors.
PMCID: PMC3070636  PMID: 21418569
19.  The contribution of STIs to the sexual transmission of HIV 
Current opinion in HIV and AIDS  2010;5(4):305-310.
Purpose of review
We review recent evidence about the link between sexually transmitted infections (STI) and HIV transmission and consider implications for control programmes.
Recent findings
New studies and meta-analyses confirm the association of HIV acquisition and transmission with recent STI, although there is considerable heterogeneity between organisms and populations. Much of the recent evidence relates to HSV-2, where the population attributable risk (PAR) percent for HSV-2 is between 25% and 35% in Africa. Mathematical models show how transmission attributable to STI varies with HIV epidemic phase, and HSV-2 becomes increasingly important as the epidemic matures. HSV-2 suppressive therapy reduces HIV concentrations in plasma and the genital tract in people co-infected with HSV, in part due to direct inhibition of HIV reverse transcriptase. Recent trials of HSV-2 suppressive therapy have not shown an impact on the risk of HIV acquisition, nor in controlling transmission from dually infected people to their sero-discordant heterosexual partners.
Although there is a plausible link between STI and HIV risk, intervention studies continue to be disappointing. This does not disprove a causal link, but mechanisms of action and the design and implementation of interventions need to be better understood.
PMCID: PMC2923028  PMID: 20543605
HIV; STI; HSV-2; preventive interventions
20.  Mapping HIV/STI behavioural surveillance in Europe 
BMC Infectious Diseases  2010;10:290.
Used in conjunction with biological surveillance, behavioural surveillance provides data allowing for a more precise definition of HIV/STI prevention strategies. In 2008, mapping of behavioural surveillance in EU/EFTA countries was performed on behalf of the European Centre for Disease prevention and Control.
Nine questionnaires were sent to all 31 member States and EEE/EFTA countries requesting data on the overall behavioural and second generation surveillance system and on surveillance in the general population, youth, men having sex with men (MSM), injecting drug users (IDU), sex workers (SW), migrants, people living with HIV/AIDS (PLWHA), and sexually transmitted infection (STI) clinics patients. Requested data included information on system organisation (e.g. sustainability, funding, institutionalisation), topics covered in surveys and main indicators.
Twenty-eight of the 31 countries contacted supplied data. Sixteen countries reported an established behavioural surveillance system, and 13 a second generation surveillance system (combination of biological surveillance of HIV/AIDS and STI with behavioural surveillance). There were wide differences as regards the year of survey initiation, number of populations surveyed, data collection methods used, organisation of surveillance and coordination with biological surveillance. The populations most regularly surveyed are the general population, youth, MSM and IDU. SW, patients of STI clinics and PLWHA are surveyed less regularly and in only a small number of countries, and few countries have undertaken behavioural surveys among migrant or ethnic minorities populations. In many cases, the identification of populations with risk behaviour and the selection of populations to be included in a BS system have not been formally conducted, or are incomplete. Topics most frequently covered are similar across countries, although many different indicators are used. In most countries, sustainability of surveillance systems is not assured.
Although many European countries have established behavioural surveillance systems, there is little harmonisation as regards the methods and indicators adopted. The main challenge now faced is to build and maintain organised and functional behavioural and second generation surveillance systems across Europe, to increase collaboration, to promote robust, sustainable and cost-effective data collection methods, and to harmonise indicators.
PMCID: PMC2959062  PMID: 20920339
21.  Geographical and demographic clustering of gonorrhoea in London 
Sexually Transmitted Infections  2007;83(6):481-487.
Gonorrhoea is an important cause of sexual ill health and is concentrated in geographical areas and demographic groups. This study explores the distribution of gonorrhoea across London.
Epidemiological data on all gonorrhoea cases were collected from 13 major genitourinary clinics in London between 1 June and 30 November 2004. Samples were stored centrally and typed using NG‐MAST. The postcode of each case's main residence was used to calculate incidence of gonorrhoea by borough using data from the UK 2001 census and a population survey on residence of men who have sex with men (MSM).
2891 cases were confirmed, 1822 of which had postcode data, resided in London, and had their strain successfully typed. There was a very high incidence of gonorrhoea in MSM (1834 per 100 000 population) and heterosexuals of black ethnicity (392 per 100 000). The incidence among heterosexuals was highest in City of London (390 per 100 000, 95% CI 213 to 566), Southwark (308 per 100 000, 95% CI 280 to 336), Hackney (284 per 100 000, 95% CI 254 to 313), and Lambeth (216 per 100 000, 95% CI 194 to 239) and was not associated with measures of social deprivation (correlation coefficient = 0.0008, p = 0.97) but was strongly associated with black ethnicity (correlation coefficient = 0.48, p = 0.01). 45% of cases had one of the 21 major strains; eight of these strains were significantly clustered geographically and persisted for a shorter duration than those that were not clustered. Patients travelled a mean of 7.7 km from their home to the clinic.
High gonorrhoea incidence in London is observed in MSM and heterosexuals of black ethnicity. Endemic strains in both MSM and heterosexuals are diagnosed at multiple clinics. Interventions, including partner notification, must therefore operate between clinics.
PMCID: PMC2220084  PMID: 17702771
epidemiology; ethnicity; geography; gonorrhoea; London
22.  Direct transmission: introducing a new feature in STI 
Peter Piot talks about STI, HIV and UNAIDS
PMCID: PMC2598719  PMID: 17911141
24.  Cancer incidence and adverse pregnancy outcome in registered nurses potentially exposed to antineoplastic drugs 
BMC Nursing  2010;9:15.
To determine the relationships of potential occupational exposure to antineoplastic drugs with cancer incidence and adverse pregnancy outcomes in a historical prospective cohort study of female registered nurses (RNs) from British Columbia, Canada (BC).
Female RNs registered with a professional regulatory body for at least one year between 1974 and 2000 formed the cohort (n = 56,213). The identifier file was linked to Canadian cancer registries. An RN offspring cohort from 1986 was created by linkages with the BC Birth and Health Status Registries. Exposure was assessed by work history in oncology or cancer agencies (method 1) and by estimating weighted duration of exposure developed from a survey of pharmacists and nursing unit administrators of all provincial hospitals and treatment centers and the work history of the nurses (method 2). Relative risks (RR) were calculated using Poisson regression for cancer incidence and odds ratios (OR) were calculated for congenital anomaly, stillbirth, low birth weight, and prematurity incidence, with 95% confidence intervals.
In comparison with other female RNs, method 1 revealed that RNs who ever worked in a cancer center or in an oncology nursing unit had an increased risk of breast cancer (RR = 1.83; 95% CI = 1.03 - 3.23, 12 cases) and their offspring were at risk for congenital anomalies of the eye (OR = 3.46, 95% CI = 1.08 - 11.14, 3 cases). Method 2 revealed that RNs classified as having the highest weighted durations of exposure to antineoplastic drugs had an excess risk of cancer of the rectum (RR = 1.87, 95% CI = 1.07 - 3.29, 14 cases). No statistically significant increased risks of leukemia, other cancers, stillbirth, low birth weight, prematurity, or other congenital anomalies in the RNs' offspring were noted.
Female RNs having had potential exposure to antineoplastic drugs were not found to have an excess risk of leukemia, stillbirth, or congenital anomalies in their offspring, with the exception of congenital anomalies of the eye, based on only three cases; however, elevated risks of breast and rectal cancer were observed.
PMCID: PMC2949748  PMID: 20846432
25.  Journal impact factors for 2006 
Sexually Transmitted Infections flies even higher
PMCID: PMC2659021  PMID: 17693448
impact factors; sexually transmitted infections

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