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Editor,—In the recent article by Stephenson et al1 the authors describe participation rates of 39% for women and 46% for men for home screening and comment “that this might form a useful component of a community based chlamydial screening programme in which non-responders could be offered opportunistic screening at the general practice.” However, certain crucial issues remain unanswered. This acceptability survey was done among women aged 18–25 years and men 18–30 years. What happens with people below the age of 18? We know that Chlamydia trachomatis prevalence is associated with young age, but can we also send home screening kits to 15 year olds? What about the parental opinions and legal implications—for example, for the partner of a C trachomatis positive youngster?
In two surveys performed in general practice in Amsterdam, Netherlands, using systematic and opportunistic screening, prevalence was strongly associated with young age but also with ethnicity. Among young Surinam-Antillian women aged <25 years, prevalences ranged from 5.4% in the systematic survey up to 22.4% in the opportunistic survey.2, 3 In the systematic survey an unexpectedly high C trachomatis prevalence of 10% was found among young Surinam-Antillian men. Among the 15–19 year olds visiting our health centre in Amsterdam which is located in a multiethnic neighbourhood, half of the population having a Surinam-Antillian background, C trachomatis prevalence was 25%.4
Thus, the question is not only how acceptable home screening is for the youngest age group, who might be most at risk, but also how acceptable home testing is for people with different ethnic backgrounds and people living in low socioeconomic status and high risk environments.
We piloted a pharmacy assisted approach offering urine home testing to all sexually active women age 15–30 years who come to our pharmacy to collect their contraceptives. Since the start 4 months ago 189 people received an information leaflet and home test package together with their contraceptives. Fifty nine participated and sent their urine; four were positive (6.7%).5 The participation rate was 31%, lower than the reported rate for women in the article of Stephenson et al.
The assumption by the authors that people who do not participate for home screening will turn up for opportunistic screening at the general practice is, however, merely a hypothesis, and not a strong one, especially not for boys and men.
Tackling issues like risk perception and risk environment and changing healthcare seeking behaviours is not an easy task. Moreover, a community based C trachomatis prevention programme will require not only secondary prevention by active case finding but also primary prevention. What is needed is an integrated set of strategies, which are mutually reinforcing and that are age, sex, culture, and context specific. Quite a challenge!
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