SSHC Journal Club presentation on the British Medical Journal and the Medical Journal of Australia Nov 2015 - Mar 2016
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Sydney Sexual Health Centre Journal Club presentation by Cherie Desreaux on the British Medical Journal and the Medical Journal of Australia editions published between November 2015 and March 2016. The Sydney Sexual Health Centre Journal Club allows our team to stay up-to-date with what is being published in the field of sexual health. Staff members take turns to read, review and share the contents of an allocated journal. Journal Club encourages knowledge sharing and discussion about topics raised.
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SSHC Journal Club presentation on the British Medical Journal and the Medical Journal of Australia Nov 2015 - Mar 2016
- 1. British Medical Journal & Medical Journal of Australia Nov 2015 - Mar 2016 BMJ - Impact factor of 17.4 (June 2015) and is ranked fifth among general medical journals. 4 or 5 editions a month each year. MJA - Australia’s leading peer-reviewed general medical journal. It has been delivering ground- breaking research to the medical community since 1914
- 2. BMJ November 2015 - News • India’s HIV prevention programme is running out of condoms, Sophie Cousins BMJ 2015 (Published 10 November 2015) Cite this as: BMJ 2015;351:h6066 • Incidence of sexually transmitted infections jumps in US, CDC reports, Michael McCarthy BMJ 2015 (Published 19 November 2015) Cite this as: BMJ 2015;351:h6263
- 3. BMJ November 2015 - News • HIV pre-exposure prophylaxis could help 1.2 million in US, Michael McCarthy BMJ 2015 (Published 25 November 2015) Cite this as: BMJ 2015;351:h6384
- 4. Jacqui Wise BMJ 2015;351:bmj.h6419 ©2015 by British Medical Journal Publishing Group New cases of HIV in Europe reach highest level since 1980s, Jacqui Wise BMJ 2015;351:h6419
- 5. Countries in the EU and EEA The European Union (EU) is an economic and political union of 28 countries. It operates an internal (or single) market which allows free movement of goods, capital, services and people between member states. EU countries The EU countries are: Austria, Belgium, Bulgaria, Croatia, Republic of Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and the UK. The European Economic Area (EEA) The EEA includes EU countries and also Iceland, Liechtenstein and Norway. It allows them to be part of the EU’s single market. Switzerland is neither an EU nor EEA member but is part of the single market - this means Swiss nationals have the same rights to live and work in the UK as other EEA nationals.
- 7. BMJ December 2015 - News • Mobile dating apps could be driving HIV epidemic among adolescents in Asia Pacific, report says, Jocalyn Clark BMJ 2015(Published 02 December 2015) Cite this as: BMJ 2015;351:h6493 • US lifts 30 year ban and allows some gay men to donate blood, Michael McCarthy BMJ 2015(Published 23 December 2015) Cite this as: BMJ 2015;351:h6982
- 8. BMJ January 2016 - Research • Patient choice in opt-in, active choice, and opt-out HIV screening: randomized clinical trial, Juan Carlos C Montoy, resident1, William H Dow, professor2, Beth C Kaplan, professor3 BMJ 2016; (Published 19 January 2016) Cite this as: BMJ 2016;352:h6895 • 2006 CDC HIV Testing Guidelines : Opt-out testing • ED well placed to identify est. 20% undiagnosed HIV • RCT in urban teaching hospital and regional trauma centre ED • Opt-in, opt-out and active choice
- 9. Fig 2 HIV test acceptance percentage by risk of infection: unadjusted results. Juan Carlos C Montoy et al. BMJ 2016;352:bmj.h6895 ©2016 by British Medical Journal Publishing Group
- 10. BMJ March 2016 - Feature • How Cuba eliminated mother-to-child transmission of HIV and syphilis, Jeanne Lenzer BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i1619 (Published 21 March 2016) Cite this as: BMJ 2016;352:i1619 • WHO announced Cuba to be first to virtually eliminate MTC transmission HIV and syphilis • <50 cases per 100 000 live births • 2013 2 babies HIV and 3 babies syphilis • ARVs versus public health initiatives
- 11. MJA February 2016 - Research • A survey of Sydney general practitioners’ management of patients with chronic hepatitis B Zeina Najjar, Leena Gupta, Janice Pritchard-Jones, Simone I Strasser, Miriam T Levy, Siaw-Teng Liaw and Benjamin C Cowie Med J Aust 2016; 204 (2): 74. • Estimated 218 000 living with CHB • 44% undiagnosed • 2 – 13 % receiving adequate treatment • Annual number of deaths from CHB expected to rise - 450 in 2008 to 1550 in 2017 • Objective – examine GP methods of assessment and management CHB
- 12. A survey of Sydney general practitioners’ management of patients with chronic hepatitis B • In NSW SLHD and SWSLHD highest prevalence of CHB • GPs identified via PHU notifications 2012 – 2013 • Survey posted to 218 GPs, 58% responded • 79% GPs expressed “reasonable” confidence at managing CHB • The greater the number of patients cared for with CHB • The greater the confidence • Liver specialist input preferred model of care • Dependence remains a barrier • Increased GP support programs needed.
- 13. MJA March 2016 – Short Report • HPV vaccine impact in Australian women: ready for an HPV- based screening program Julia ML Brotherton, Dorota M Gertig, Cathryn May, Genevieve Chappell and Marion Saville Med J Aust 2016; 204 (5): 184. • 2017 Australia moving to HPV DNA testing • HPV screening to commence at 25 • Possible due to HPV vaccination • Prevalence in young women dramatic decline
- 15. MJA March 2016 - Research • Impact of HPV sample self-collection for underscreened women in the renewed Cervical Screening Program Megan Smith, Jie Bin Lew, Kate Simms and Karen Canfell Med J Aust 2016; 204 (5): 194. • 2017 National screening program moves to 5-yearly primary HPV screening • Outcome measures were how many cancer diagnoses and deaths would be averted. • Dynamic model of HPV transmission and vaccination • Cohort model of HPV natural history and cervical screening • 3 choices for unscreened women
- 16. Impact of HPV sample self-collection for underscreened women in the renewed Cervical Screening Program • Single round of HPV testing on a self-collected sample • Single round of HPV testing on a clinician-collected sample • Joining the mainstream screening program (5-yearly) • The comparator – remaining unscreened • Age 30 and one self-collected sample estimated 908/100 000 cancer diagnoses averted, NNT 5.8 • Age 30 and joined the mainstream program diagnoses averted would more than double 2002/100 000, NNT 4.9 • Previously unscreened women to be encouraged to join
- 17. Socio-demographic and structural barriers to being tested for chlamydia in general practice Andrew Lau, Simone Spark, et al Med J Aust 2016; 204 (3): 112. Objectives To investigate socio-demographic and structural factors associated with not providing a specimen for chlamydia testing following a request by a general practitioner Design, setting and participants: Cross-sectional analysis of chlamydia testing data for men and women aged 16–29 years attending general practice clinics participating in a cluster randomised controlled trial evaluating the effectiveness of a chlamydia testing intervention (ACCEPt). Data extrapolated for the study period the 2013 calendar year. Outcome: The proportion of chlamydia test requests for which the patient did not provide a specimen for testing.
- 18. Socio-demographic and structural barriers to being tested for chlamydia in general practice Methods •All CT test requests from 1 January – 31 December 2013 •Factors associated with “no test performed” outcome explored using logistic regression •Univariate ORs, multivariate ORs, and 95% CI were calculated •Intervention arm of the ACCEPt study only used for this analysis •Total of 63 intervention clinics
- 19. Socio-demographic and structural barriers to being tested for chlamydia in general practice Results •Overall annual testing rate 19.2% (CI 16.8-21.8%) •13 225 CT tests requested •73% were for women •29% were for 16-19 year olds •21% requested at Melbourne clinics •55% at inner regional clinics •22% at outer regional settings •2% in remote settings •31% were bulk-billing & 92% onsite specimen collection
- 20. Socio-demographic and structural barriers to being tested for chlamydia in general practice • 2545 no test (19.2%, CI 16.5-22.3%) • Univariate analysis, most likely to not have test if: – Male – 16 – 19 years old – Greater socio-economic disadvantage area Multivariate analysis also found – No onsite specimen collection No association with “No Test” – geographic location, bulk-billing or ATSI
- 21. Socio-demographic and structural barriers to being tested for chlamydia in general practice Discussion •1 in 5 young people •Men and 16-19 year olds •Living in areas of greater socio-economic disadvantage •Attending clinics with no onsite specimen collection (likelihood of no test 40% greater in this group) All predictors for not providing a specimen for CT testing Important fact Younger age and socio-economic disadvantage risk factors for CT infection.
- 22. Finally • The author’s acknowledged there were a number of limitations why test was ordered? mostly rural settings, generalisable?? unable to look at clinic specifics patient symptomatic/asymptomatic • Strengths Large sample Considered area, clinic, and patient level factors
Editor's Notes
- News A prevention program in India that is said to have averted 3 million HIV infections between 1995 – 2015 has been stripped of one fifth of it’s funding resulting in a condom shortage as these were supplied and distributed for free within communities. Despite India having the third largest prevalence of any country there is a lack of political support to maintain and continue this simple initiative. This next news article comes from a CDC report that found the time between 2013-2014 saw increases in STIs amongst all high risk populations. CT increased by 3% gono by 5% and primary and secondary syphilis by &gt;15% with an increased burden amongst gay and bisexual males for all infections, CT was more prevalent amongst women, who are also screened more, and greater rates seen in American Indian, Alaskan native and African American women. The same ethnic and racial groups also saw increases in gono prevalence. The increase in syphilis diagnoses was predominantly in males 91%, with gay and bisexual men forming 83%. Women who were American Indian, Alaskan native or African American had 22% increase in syphilis diagnoses and congenital syphilis rose by 27.5% with African American populations 10 times more likely to experience congenital syphilis. The CDC report was promoting annual screening for all women under 25 for CT and gono, Early pregnancy screening for CT, HIV, Hep B and syphilis and additional gono screening if reporting multiple partners, and gay and bisexual men to have annual HIV, syphilis, gono and CT screening, more often if engaging in high risk activities.
- News This first article was commenting on report from the US CDC that PrEP providers (GPs) lacked understanding and awareness of the benefits of PrEP for those at increased risk of HIV transmission and as a result only 1/3 of those at risk were actually receiving PrEP.
- WHO regional office in Europe and the European Centre for Prevention and Disease Control reported 142 197 new HIV diagnoses in 2014 with 77% from the Eastern region of Europe. Bulgaria, Czech Republic, Hungary, Malta, Poland and Slovakia had seen new diagnoses double since 2005, Rates of new HIV diagnoses fell in 11 countries, and decreases of more than 25% were seen in Austria, Estonia, France, the Netherlands, Portugal, and the United Kingdom. Eastern European increases were mostly heterosexual transmission and diagnosis as a result of injecting drug use remained high. Almost ½ of the new diagnoses were late with CD4 counts below 350. Overall transmission in the European Union and the European Economic Area was greatest amongst gay and bisexual men.
- In 2006 the CDC updated HIV testing guidelines and made recommendation for opt-out testing for non-target populations and identified Eds as being in good position to capture the 20% estimated to be living with HIV undiagnosed. The researchers wanted to assess HIV testing acceptance using the 3 methods of Opt-in, Opt-out and Active choice as most hospitals had not taken up the CDC recommendations for testing. The study was presented as part of routine ED patient care, a 10 minute questionnaire was offered and a standardised script was given to inform about the availability of HIV testing. The script went something like, “We are offering all patients HIV testing. It is a rapid test with results available in 1 to 2 hours.” Depending on which arm the patient was randomised to the remainder of the script was For Opt-in “You can let me, your nurse or doctor know if you’d like a test today” For Active choice “would you like a test today?’ For Opt-out “You will be tested unless you decline”
- The study was conducted over 2 years 2011 – 2013 there were 5801 offered testing and 4800 consented Fig 2 HIV test acceptance percentage by risk of infection: unadjusted results. Test acceptance percentage is shown according to treatment assignment (opt-in, active choice, and opt-out), and according to risk of HIV infection. Lines indicate 95% confidence intervals. Numbers of patients from each risk category accepting and offered HIV testing under each treatment group are presented as numerator and denominator The end result was Opt-out generated a greater acceptance for HIV testing, and active choice had a greater acceptance for testing than the Opt-in method and there was higher testing uptake in those identified as either intermediate or high risk, however there was no difference in test acceptance across all 3 arms if there was any reported risk for HIV, so risk alone irrelevant of the way a test is offered = test acceptance. The researchers stated that although decision aids have been shown to influence patient decisions this study shows how a one sentence variation can dramatically impact their decisions and our perceptions of the pat preference.
- Unlike BMJ, the MJA had more research relevant to sexual health than news. Albeit a small selection there were atleast some studies to review. There’s an estimated 218 000 people living with chronic hep B in Australia and up to 44% of those infected are undiagnosed. Despite the availability of treatments that reduce the likelihood of morbidity and mortality only 2 – 13% of those living with CHB are receiving adequate treatment. The number of deaths attributable to CHB is predicted to rise from 450 in 2008 to 1550 in 2017. The National Hep B strategy 2014-2017 recommends an increased role for GPs in assessment and management of patients with CHB, so the study objective was to examine GP methods of CHB assessment and management and to gauge their views on models of care.
- The highest prevalence of CHB in NSW is within the Sydney and South West Sydney LHDs, due to large populations of people from countries with intermediate or high prevalence of CHB. The researcher’s received a list of GPs who had notified the local PHU of a CHB diagnosis over a 12month period mid 2012 – 2013. There were 218 GPs identified of which 58% completed the surveys posted to them. The assessment, management and referral practices of GPs were measured along with their opinions about different models of care. 79% of those who responded felt reasonably confident at managing CHB and the larger the number of patients on the GPs list with CHB reflected an increased confidence with assessment and management. The overall preferred model was initial referral to a liver specialist following diagnosis and then ongoing Mx by the GP. No liver specialist input or only review by a specialist nurse was less favoured. The researchers noted that dependence on specialist input remained the biggest barrier to appropriate assessment and management of CHB patients by GPs, increased support programs for GPs needed.
- In 2017 Australia is moving to HPV DNA testing for all women whether they have had the HPV vaccine or not, and HPV screening is to commence at the age of 25. Following the HPV vaccination program in Australia between 2007 and 2009 which saw more than half of 12 – 26 year olds fully vaccinated there has been a dramatic decline in the prevalence of HPV 16 and 18 in young women. Despite the continued increase in HPV prevalence amongst older women during the vaccination period (suggested to be consistent with the underlying trend of infection and increased screening due to health promotion) we are now able to see the benefits of vaccination against HPV for Australian women in the form of evidence-based protection via ongoing reductions in prevalence as those vaccinated age.
- This slide highlights the Trends in prevalence rates of high grade histologically confirmed cervical abnormalities diagnosed in Victorian women by age group. In 2007 the youngest was 12 and the oldest 26 making these young women 19 and 33 in 2014 and it’s within these age groups there has been the greatest decline in numbers of women diagnosed with high grade cervical abnormalities.
- This follows on from the last article and looks at the potential impact on future risk of cervical cancer in the unscreened or underscreened 30 – 74 year old age range. The desired outcome measures were to see how many cancer diagnoses and deaths would be averted by age 84. To do this the researchers used a dynamic model purported to be the most comprehensive of HPV epidemiology, and the HPV natural history model to be well established. They used 3 choices for screening for previously unscreened women.
- The options considered were one self-collected sample, one clinician collected sample and the assumption that neither of these groups would return for further screening, or to join the program. These were all compared to the possibility of women choosing to remain unscreened. After a lot of fancy analysis the researchers found – one self-collected sample at age 30 would avert 908/100 000 cancer diagnoses and 364/100 000 deaths by age 84 and the NNT would be 5.8, there were ongoing diagnoses and deaths averted if screening was delayed to 40 and 50 years of age however if at age 30 unscreened women joined the mainstream program the number of diagnoses averted jumped to 2002 and the NNT dropped to 4.9. The benefits of joining the mainstream program were similar to that found amongst those vaccinated. Despite the benefits of self-collected HPV testing samples women who have previously never screened or who are more than 2 years overdue should still be encouraged to join the mainstream screening program.
- We know that GPs are at the forefront of health care in Australia and that chlamydia screening is recommended for all sexually active young people aged between 15 – 29 years however less than 10% of this age group are screened in GP land. So the researchers aimed to examine the factors associated with a patient not providing a specimen for CT testing despite the GP requesting the sample. The reason I chose this article was that question….I had not contemplated the possibility that maybe GPs were ordering the tests but it’s the patient not following through that is part of the problem with low screening rates in the GP setting. The ACCEPt study was utilised to examine data on 16 – 29 year old men and women from all over Australia with a total of 142 clinics recruited mostly rural and regional with 8 GP clinics from Melbourne included. The inclusion criteria for the towns was a population of no less than 500 16 – 29 year olds and less than 7 GP clinics. In order to link and gather data each clinic had a data extraction tool installed on their computers, 20 weren’t able to have the tool installed, a variety of reasons provided from no computers to refusing to have the tool installed. Data collected included age, sex, clinic postcode, CT test requested yes or no, CT test result – positive, negative or test not done. Additional information collected included bulk-billing clinic, specimen collection available on site, the ABS was used to assess the socio-economic profile based on postcode and the geographical location of the clinic was also classified in order to assess remoteness.
- For the calendar year of 2013 all CT tests requested were extracted from the data. The decision to use just the intervention clinics was made due to data availability and consequently there were a total of 63 intervention clinics analysed for the purpose of this study. Logistic regression was used to explore factors associated with no test being performed.
- For 2013 the overall annual testing rate was 19% and there was a total of 13 225 CT tests requested of which 73% (9712) were for women. From the overall total 29% of the tests requested were for 16-19 year olds with inner regional clinics requesting most of these tests, 1/3 offered bulk-billing for students and young adults and most clinics had onsite specimen collection.
- Of the 13 000 CT tests requested there were 2 545 tests not performed. A univariate analysis indicated that men were more likely not to have the test, be 16 – 19 years old, and likely to be living in a disadvantaged socio-economic region. The multivariate analysis confirmed these findings plus the addition of those attending clinics without onsite collection. The geographic location, access to bulk-billing, and the proportion of the population identifying as ATSI were not associated with a test not being done.
- In order to assess selection bias the researchers analysed 59 control clinics for the same variables and found no difference between intervention or control clinics The authors discussion reiterate that males, young people, people living in areas of lower socio-economic status and those attending clinics with no onsite specimen collection are all predictors for not following through with a Ct test, and suggest that GP clinics need to arrange systems to ensure that tests ordered are completed. They also commented on a couple of UK studies that had identified young men as at risk of not testing for CT and noting reasons such as that men’s attitudes to chlamydia screening were affected by a lack of knowledge and social embarrassment about chlamydia, a reluctance to seek medical help, a perception that chlamydia was a “women’s disease”, and indifference to health promotion campaigns.22 We found that those aged 16–19 years were less likely to undergo a test requested by a GP. It is possible that concern about confidentiality and privacy in general practice may have deterred some from chlamydia screening.10 Young people are also less likely to undergo annual health checks or to seek health information,23 and they express uncertainty or misconceptions about what the test entails.24 It has been argued that simply raising awareness about the risk of chlamydia may not increase testing rates, and that providing reassurance of non-infection may be more productive.25 Setting up onsite testing should be considered as most pathology providers offer courier services.
- My thoughts…….