STI prevention and control research group
Sexually transmitted infections remain a major health problem globally and locally. We use a broad range of research tools to explore the epidemiology of STI with a view to informing interventions. We work closely with social scientists, clinicians, laboratory researchers and public health policy makers.
Leader: Helen Ward
Members: Zahid Asghar, Kelsey Case, Geoff Garnett, Neil Macdonald, Peter White,
Research students: Gabriella Gomez
Research topics
- Outbreaks of STI
- Sexual networks and molecular epidemiology
- Sex work research
- Newly acquired HIV infection
- Intervention studies
- Health Services Research
Syphilis remains a major health problem globally and continues to challenge even the most developed health systems. In the UK syphilis was almost eradicated in the mid-1990s, but reappeared with a series of outbreaks starting in 1997. These outbreaks are continuing among men who have sex with men, many of whom have HIV infection, with increasing numbers in heterosexual men and women. Cases of syphilis in the have now reached levels not seen since the late 1940s. We were awarded a grant from the Medical Research Council in 2005 to model these outbreaks and develop an epidemiological tool for the local management of outbreaks, in collaboration with clinicians and public health specialists.
Lymphogranuloma venereum (LGV) is a sexually transmitted disease caused by serovars L1-3 of the common bacteria Chlamydia trachomatis. LGV is highly prevalent in parts of Africa, Asia, and but has been rare in western Europe for many decades. LGV is a chronic disease that has a variety of acute and late manifestations. If left untreated it can cause lasting damage to health. Since 2003 a series of outbreaks of LGV have been reported in European cities among men who have sex with men (MSM). Helen Ward chairs the HPA LGV incident team which is monitoring the outbreak, investigating risk factors and leading the response. We are working closely with the HPA to develop recommendations for testing and screening policies based on case control studies of men with LGV proctitis compared with other chlamydial serovars, and a case finding study to determine the prevalence and clinical spectrum of rectal chalmydia infection in MSM.
(http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/LGV/lgv.htm
Selected publications
Ward H; Martin I; Macdonald N; Alexander S; Simms I; Fenton K; French P; Dean G; Ison C. (01 Jan 2007). Lymphogranuloma venereum in the United kingdom. Clin Infect Dis. 44:26-32. Publisher weblink DOI.
Simms I, Ward H. Congenital syphilis in the UK : are we prepared? (Editorial) Sex Transm Inf 2006;82(1):2
Macdonald N, Ison CA, Martin I, Alexander S, Lowndes C, Simms I, Ward H. Initial results of enhanced surveillance for lymphogranuloma venereum (LGV) in England. Eurosurveillance Weekly 2005;10(4) http://www.eurosurveillance.org/ew/2005/050127.asp
P French, C A Ison, and N Macdonald Lymphogranuloma venereum in the United Kingdom Sex. Transm. Inf., Apr 2005; 81: 97 – 98
Martin IMC, Alexander SA, Ison CA, Macdonald N , McCarthy K, Ward H. Diagnosis of Lymphogranuloma venereum (LGV) from biopsy samples. GUT 2006 (research letter, in press)
Ward H. Lymphogranumola Venereum (LGV) in the : national surveillance of a re-emerging disease. Presentation at the CDC 2006 National STD Prevention Conference, Jacksonville, May 2006. http://cdc.confex.com/cdc/std2006/techprogram/P12179.HTM
Sexual networks and molecular epidemiology
The transmission of STI in a population depends on who has sex with whom, and the sexual networks that these links produce. Empirical research into the structure of sexual networks is difficult, and over the last decade we have developed methods to combine detailed behavioural research on sexual networks with the additional information gleaned from a study of the molecular subtypes of the organisms. Through work on gonorrhoea we have identified the relative importance of local endemic strains which are poorly controlled, and proposed mechanisms for improving surveillance and control using molecular typing and enhanced partner notification.
Selected publications
Risley CL; Ward H; Choudhury B; Bishop CJ; Fenton KA; Spratt BG; Ison CA; Ghani AC. (01 Oct 2007). Geographical and demographic clustering of gonorrhoea in London. SEX TRANSM INFECT. 83:481-487. DOI.
Choudhury B, Risley CL, Ghani AC, Bishop CJ, Ward H, Fenton KA, , Spratt BG. Gonorrhoea in London: Identifying Individuals within Sexual Networks. Lancet, 2006;368:139-146
Ward H, Ison CA, Day SE, Martin I, Ghani AC, Garnett GP, Bell G, Kinghorn G, Weber J. A prospective social and molecular epidemiological investigation of gonococcal transmission. Lancet 2000;356:1812-17
Day S, Ward H, Ison C, Bell G, Weber J. Sexual networks: the integration of social and genetic data. Social Science and Medicine 1998;47(12):1981-1992
Parker M, Ward H, Day S. Sexual networks and the transmission of HIV in . Journal of Biosocial Science 1998;30(1):63-83
Sex work research
Helen Ward and Sophie Day have worked with sex workers for 20 years to understand the role of prostitution in society and to try to challenge the stigma that apportions blame to sex workers as transmitters of disease and immorality. We have carried out extensive work on the epidemiology of STI in sex workers and their clients in the and , and established health and advocacy projects. In a unique cohort study we have looked at the long term impact of sex work on health, we have concluded that the adverse outcomes, in terms of infection and mental health, are as much the result of stigma as the result of multiple sexual partnerships.
Selected publications
Day S and Ward H (eds) Sex work, mobility and health in Europe. Kegan Paul, London, 2004
Ward H, Day S. What happens to women who sell sex? Results from a unique occupational cohort. Sex transm inf 2006 Published Online First: 21 June 2006. doi:10.1136/sti.2006.020982
Sethi G, Holden B, Gaffney J, Greene L, Ghani A, Ward H. HIV, sexually transmitted infections and risk behaviour in male sex workers in London over a 10 year period. Sex transm inf 2006 (in press)
Fox J, Day S, Taylor G, Ward H. The epidemiology of HSV-2 in female sex workers in London Epidemiol Inf 2006;Mar 29;1-6 (Epub ahead of print) doi: 10.1017/S0950268806006133
Ward H, Mercer C, Wellings K, Erens B, Copas A, Fenton K and Johnson AM. Who pays for sex? An analysis of the increasing prevalence of female commercial sex contacts among men in Sex Transm Inf 2005;81:467-471:
Newly acquired HIV infection
People who have recently been infected with HIV (primary HIV infection) have a high viral load and are potentially highly infectious. Early identification of primary HIV may allow behavioural and biomedical interventions that could reduce onward transmission. We have measured the changes in sexual risk behaviour in people who have recently been diagnosed with PHI and are modelling the potential impact of behaviour and of antiretroviral therapy on onward transmission.
Intervention studies
People who have had an STI are at increased risk of acquiring another due to ongoing risk behaviour or re-infection from an untreated contact. A number of behavioural interventions have been shown to reduce risk behaviours in this situation, but generally require considerable resources with intensive counselling. We are carrying out a trial of an innovative behavioural intervention delivered via the internet, SHIFT (Sexual Health Internet Facilitated Trial, ISRCTN16344388).
Health Services Research
There is a much reported “crisis” of sexual health services in the , with rising rates of STI and long waits for care. We have modelled the potential impact of treatment delays on gonorrhoea rates, and found:
“At the high incidence equilibrium, there is a vicious circle in which inadequate treatment capacity leads to untreated infections generating further incidence and high demand, maintaining the inadequacy of services. A substantial increase in capacity is needed to interrupt this process and enter a virtuous circle in which adequate service provision keeps demand low, offering cost savings as well as improvements in health.” 1
This work has informed policy discussions at the Department of Health and supported the drive for improved access to services across the . We continue to work on capacity and access issues in collaboration with the HPA, Department of Health and BASHH (the British Society for Sexual Health and HIV).
Selected publications and links
White PJ, Ward H, Cassell JA, Mercer CH, Garnett GP. Vicious and virtuous circles in the dynamics of infectious disease and the provision of health care: gonorrhoea in as a model. Journal of Infectious Diseases 2005;192:824-836
Summary of paper: http://www.bashh.org/committees/cgc/funding/summary_white_vicious_circles_1005.pdf
Panorama report of the modelling work: http://news.bbc.co.uk/1/hi/programmes/panorama/4348016.stm
Home page of the Panorama documentary, Love Hurts: http://news.bbc.co.uk/1/hi/programmes/panorama/4334310.stm
