What do Key Stakeholders Think About HIV Self-Testing in Canada? Results from a Cross-Sectional Survey.

Human immunodeficiency virus (HIV) self-testing presents an empowering alternative to facility-based testing for reaching undiagnosed HIV infected individuals, but is not currently available in Canada. We surveyed stakeholders (clinical providers, public health professionals, researchers) engaged in HIV testing initiatives nationwide to identify the concerns, opportunities and challenges to implementing HIV self-testing in Canada. An online cross-sectional survey was disseminated by the Canadian Institutes of Health Research Centre for REACH 2.0 National HIV & sexually transmitted and blood borne infections working group to stakeholders nationwide, with a target sample size of 200. Quantitative and qualitative data were analyzed using a mixed-methods, respondent-informed approach, to inform subsequent HIV self-testing in a country where self-testing is not yet accessible. A total of 183 responses were received. A majority (70.7%) (128/181) felt that self-testing was a necessary investment to reach the undiagnosed. 64.6% (117/181) felt that self-tests should be made available to their clients and 71.5% (128/179) of respondents agreed that self-test instructions required improvements. However, 50% (90/180) felt that self-testing will pose an economic challenge to current HIV testing models. Regardless, 21% urged for timely action and availability of HIV self-tests. Thematic analyses reflected the following concerns: (a) need for affordable self-tests, (b) need for expedited, customized, and accessible linkages to counselling, (c) concern for patients to cope with positive self-test results, (d) accuracy of self-tests to detect acute HIV and (e) liability in the context of non-disclosure. Stakeholders agreed to the provision of an option of HIV self-testing to reach the undiagnosed individuals. Concerns regarding costs and accuracy of self-tests, expedited linkages to counselling, and integration of self-test within prevailing HIV testing models, will need to be addressed before their widespread implementation.

Does suppressive antiviral therapy for herpes simplex virus prevent transmission in an HIV-positive population? A systematic review.

BACKGROUND: Among individuals with genital herpes simplex virus (HSV), co-infection with human immunodeficiency virus (HIV) has been shown to increase the frequency and severity of HSV symptoms, HSV shedding, and risk of HSV transmission. OBJECTIVE: To assess whether suppressive antivirual therapy for genital HSV in an HIV-positive populatation prevents HSV transmission to a susceptible partner. METHODS: A systematic search of the literature was conducted using MEDLINE and EMBASE databases to identify randomized controlled trials published between January 2005 and June 2015. Inclusion criteria were trials written in English or French utilizing suppressive antiviral therapies for HSV. Studies had to report on outcomes related to HSV transmission from HIV-positive populations. Surrogate markers of HSV transmission risk, such as HSV detection and viral load, were also included. Articles underwent a risk of bias assessment, and those with low risk of bias underwent data extraction to complete a narrative synthesis. RESULTS: This review identified thirteen papers. Only one study directly measured transmission of HSV. The overall transmission rate was <10%, and suppressive antiviral therapy had no significant protective effect (9% transmission rate in the acyclovir group vs. 6% in the placebo group; hazard ratio [HR]: 1.35, 95% CI: 0.83-2.20). The remaining 12 papers addressed surrogate markers of transmission risk: HSV detection and viral load. Suppressive acyclovir appears to be effective in reducing HSV detection among HIV-positive populations, but it does not appear to reduce viral load. Suppressive valacyclovir may be effective in reducing HSV detection and viral load among HIV-positive patients who are antiretroviral therapy (ART)-naïve, but its effect appears to be nullified among those concurrently on ART. CONCLUSION: Based on current evidence, suppressive antiviral therapy may reduce HSV detection and viral load, but its impact on HSV transmission is unclear. Clinicians should caution HIV-positive patients with HSV that suppressive therapy may not reduce risk of HSV transmission to susceptible partners.

Squamous anal cancer: patient characteristics and HPV type distribution.

BACKGROUND: Infection with high risk human papillomavirus (HPV) is strongly associated with anal cancer. However, detailed studies on HPV type distribution by gender and age are limited. METHODS: Retrospective study of 606 invasive anal cancers diagnosed between 1990 and 2005 in two large urban areas of the province of Québec, Canada. Cases were identified from hospitalization registry. Patient characteristics were collected from medical files. Archived anal squamous cancer specimens were available from 96 patients and were tested for HPV DNA and typing. Variant analysis was performed on 16 consecutive and 24 non-consecutive HPV16-positive samples to assess potential contamination during amplification. RESULTS: Among the 606 patients with anal cancers, 366 (60%) were women. Median age at diagnosis was 63 years. HPV was detected in 88/96 (92%) of cases. HPV16 was the most frequent type detected in 90% of HPV-positive specimens. Other types including 6, 11, 18, 33, 52, 53, 56, 58, 62 and 82 were also found. HPV 97 was not detected. HPV prevalence was associated with female gender and younger age. No contamination occurred during amplification as shown by the subset of 41 HPV16-positive samples, as 37, 2 and 1 isolates were from the European, African and Asian lineages, respectively. The most frequent variants were G1 (n=22) and the prototype (n=12). CONCLUSIONS: Women with anal cancer are at higher risk for anal HPV infection, and HPV infection, especially HPV16, is strongly associated with squamous anal cancer. Therefore, HPV vaccine could potentially prevent the occurrence of anal cancer in both men and women.

Evolution of cervical cancer screening and prevention in United States and Canada: implications for public health practitioners and clinicians.

OBJECTIVE: Declines in cervical cancer incidence and mortality in Canada and in the United States have been widely attributed to the introduction of the Papanicolaou (Pap) test. This article reviews changes in screening and introduction of HPV vaccination. METHOD: Sentinel events in cervical cancer screening and primary prevention through HPV vaccination in the US and Canada are described. RESULTS: Despite commonalities, cervical cancer screening and prevention differ between the two countries. Canada has a combination of opportunistic and organized programs at the provincial and territorial level, while the US has opportunistic screening and vaccination systems. In the US, the HPV test along with the Pap test (co-testing) is part of national recommendations for routine cervical cancer screening for women age 30 and older. Co-testing is not being considered anywhere in Canada, but primary HPV testing is currently recommended (but not implemented) in one province in Canada. CONCLUSION: Many prevention strategies are available for cervical cancer. Continued public health efforts should focus on increasing vaccine coverage in the target age groups and cervical cancer screening for women at appropriate intervals. Ongoing evaluation will be needed to ensure appropriate use of health resources, as vaccinated women become eligible for screening.

Prevalence and correlates of cervico-vaginal clinical syndromes among women attending a health camp in Lalitpur district of Nepal.

BACKGROUND: Sexual and reproductive health of women is a major public health problem in Nepal. Screening of cervico-vaginal clinical syndromes could potentially provide insights to the prevalence of sexually transmitted infections (STIs), which is not known. OBJECTIVE: To investigate the prevalence and factors associated with cervico-vaginal clinical syndromes in the socio-behavioral, medical, and public health context of Nepal. METHODS: Married women attending a clinical health camp held by the Nepal Fertility Care Centerin Khokana of Lalitpur district were recruited to the study. Seventy-three participants completed face-to-face questionnaires on basic socio-demographic, behavioral and reproductive health factors and underwent pelvic screening including clinical diagnosis of cervicitis and vaginitis. An univariate analysis was performed to determine if any of the self-reported variables were associated with abnormal pelvic examination (cervicitis and/or vaginitis). RESULTS: Vaginitis was diagnosed in three (4.4%) participants, while cervicitis was detected in 16 (23.5%) women. None of the participants reported any high risk sexual behavior. However, 28% of the participants reported having had STI diagnosis in the past and was associated (P<0.008) with abnormal pelvic results. Additionally, women with lower education were associated (p<0.02) with abnormal pelvic results. CONCLUSIONS: The high occurrence of cervicitis in our exploratory could indicate the high prevalence of STIs. However, while there could potentially be an unknown epidemic of STIs related to the clinical syndromes, point of care testing practice might help to understand the true prevalence of STIs in Nepali women and also reduce the health burden and consequences of over treatment based on the current symptomatic diagnosis.

Knowledge, attitudes and behaviours associated with the provision of hepatitis C care by Canadian family physicians.

The role of primary care physicians in providing care for hepatitis C virus (HCV) infection is increasingly emphasized, but many gaps and challenges remain. This study explores family physicians' knowledge, attitudes and practices associated with providing care for HCV infection. Seven hundred and forty-nine members of the College of Family Physicians of Canada (CFPC) completed a self-administered survey examining knowledge, attitudes and behaviours regarding HCV infection screening and care. Multivariate analyses were performed using the outcome, HCV care provision, and variables based on a conceptual model of practice guideline adherence. Family physicians providing basic-advanced HCV care were more likely to be older, practice in a rural setting, have injection drug users (IDU) in their practice and have higher levels of knowledge about the initial assessment (OR = 1.77; 95% CI = 1.23-2.54) and treatment of HCV (OR = 1.74; 95% CI = 1.24-2.43). They were also less likely to believe that family physicians do not have a role in HCV care (OR = 0.41; 95% CI = 0.30-0.58). Educational programmes should target physicians less likely to provide HCV care, namely family physicians practicing in urban areas and those who do not care for any IDU patients. Training and continuing medical education programmes that aim to shift family physicians' attitudes about the provision of HCV care by promoting their roles as integral to HCV care could contribute to easing the burden on consultant physicians and lead to improved access to treatment for HCV infection.

The evolution of HPV-related anogenital cancers reported in Quebec - incidence rates and survival probabilities.

Non-cervical anogenital cancers (i.e. anal, vulvar, vaginal and penile cancers) associated with the human papillomavirus (HPV), for which HPV is known to be the necessary cause of carcinogenesis, are poorly documented due to their relatively low incidence rate. The aim of this study is to describe the incidence rates of these cancers between 1984 and 2001, and their relative survival probabilities, in Quebec (Canada) between 1984 and 1998. The incidence of these cancers is on the rise, particularly anal cancer in women and, more recently (since 1993-95), vulvar cancer. Between 1984-86 and 1993-95, the 5-year relative survival probability for men with anal cancer decreased from 57% to 46%, while that for penile cancer dropped from 75% to 59%. However, during the same period, the 5-year relative survival probability for women with anal cancer rose from 56% to 65%, and remained stable for cervical and vulvar cancers, at 74% and 82%, respectively.

Hepatitis C virus is related to progressive liver disease in human immunodeficiency virus-positive hemophiliacs and should be treated as an opportunistic infection.

The hypothesis was investigated that hepatitis C virus (HCV) infection behaves like an opportunistic infection in which progressive liver disease (PLD) is the principal manifestation. PLD in 81 hemophiliacs coinfected with HCV and human immunodeficiency virus (HIV) was compared with 53 HIV-seronegative HCV-infected hemophiliacs. Progression to AIDS and death in 22 HCV/HIV-coinfected hemophiliacs with PLD was also compared with 59 coinfected hemophiliacs who did not develop PLD. The risk of PLD occurrence associated with an HIV-positive status was 7.4 (95% confidence interval [CI], 2.2-25.5; Cox model). In the coinfected group, the risk of PLD occurrence was higher in subjects with severe AIDS-defining immunodeficiency than in those without (odds ratio, 3. 6; 95% CI, 1.3-10). Persons with PLD also had a faster progression to AIDS (P=.03, log rank test) than those without PLD. Thus, as with other chronic resident human viruses, HCV should be considered another opportunistic pathogen in HIV disease.

Short-course itraconazole in the treatment of candida vulvovaginitis: A multicentre Canadian study.

OBJECTIVE: To determine the clinical and mycological effectiveness of oral itraconazole in the treatment of acute candida vulvovaginitis. DESIGN: A prospective, randomized and single-blinded, multicentre trial of 221 women, comparing a one-day course of oral itraconazole 200 mg bid with vaginal clotrimazole 500 mg single-dose therapy. MAIN OUTCOME MEASURES: Symptoms, signs and mycological results were assessed up to two months following treatment. Adverse events were recorded and evidence of hepatotoxicity sought. RESULTS: At 10 and 30 days post-treatment, clinical and mycological cure rates were similar (61.3% clinical and 88.6% mycological 10 days after, and 67.7% clinical and 79.5 mycological 30 days after itraconazole; 64.0 clinical and 85.9% mycological 10 days after, and 62.1% clinical and 78.6 mycological 30 days after clotrimazole) with the majority of both treatment groups free from infection. A total of 69 patients reported adverse events, which were generally transient and mild. Itraconazole was more often associated with gastrointestinal or central nervous system complaints, while clotrimazole recipients more often had genitourinary symptoms. No evidence of hepatotoxicity was found. A higher incidence of relapse was noted among women on the birth control pill and among those who were symptomatic for longer than 10 days before treatment. CONCLUSIONS: A one-day course of oral itraconazole is as effective as intravaginal clotrimazole in the treatment of acute yeast vulvovaginitis. The number of patients reporting adverse events was similar for the treatment groups, although the side effect profile differed. No hepatotoxicity was observed.

Interest of biotyping Candida albicans in chronic vulvovaginitis.

Chronic vulvovaginitis due to Candida albicans is a major clinical problem for the physician. Although new antifungal drugs are now available, the therapeutic approach of this disease remains disappointing. The aims of this study were two-fold. First, we wanted to evaluate the reliability of a single sampling performed by most clinicians in verifying if the yeast infects the entire genital mucosa or a preferential site and, second, to biotype the strains recovered in order to see if more than one strain are responsible for the infection. We found, in 18 patients suffering from vaginal candidosis, that the entire genital mucosa was infected by the yeast and the strain recovered from the different genital sites in a single patient was the same in 100% of the cases. Only 1.4% of the samples were negative. In addition, we biotyped the strains obtained from the gastrointestinal tract of these patients to evaluate this site as a potential source of infection. We obtained gastrointestinal tract samples for 15 of the 18 patients and we could identify C. albicans in 100% of the cases. Furthermore, 73.3% of the patients harboured the same strains of C. albicans in the gastrointestinal tract as in the vagina.

[Not Available]. / Réflexions sur le rôle du médecin de famille comme éducateur sanitaire.

The family physician's role in health promotion must be looked at in a broader perspective than the traditional clinical setting, and better articulated to public health organizations. Medical faculties should consider including sociology, medical anthropology, and communication skills in both the undergraduate and postgraduate curriculum. Family physicians of the future will be called upon for more community-wide basis interventions and a more systematic approach to health promotion in patient care.

AIDS: acquired immunodeficiency syndrome.

Acquired immunodeficiency syndrome, or AIDS, is a new illness that occurs in previously healthy individuals. It is characterized by immunodeficiency, opportunistic infections and unusual malignant diseases. Life-threatening single or multiple infections with viruses, mycobacteria, fungi or protozoa are common. A rare neoplasm, Kaposi's sarcoma, has developed in approximately one third of patients with AIDS. More than 800 cases of AIDS have been reported in North America, over 24 of them in Canada. The majority of patients are male homosexuals, although AIDS has also developed in abusers of intravenously administered drugs, Haitian immigrants, individuals with hemophilia, recipients of blood transfusions, prostitutes, and infants, spouses and partners of patients with AIDS. The cause of AIDS is unknown, but the features are consistent with an infectious process. Early diagnosis can be difficult owing to the nonspecific symptoms and signs of the infections and malignant diseases. Therefore, vigilance by physicians is of utmost importance.