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Every autumn STI publishes a double issue, and we are delighted that this month's journal is accompanied by a special issue focussing on gonorrhoea. Few of you will be unaware of recent headlines in the medical and lay press, emphasising our vulnerability to a new post-antibiotic era. Cathy Ison and Gwenda Hughes have done a magnificent job as Guest Editors in pulling together an issue with clinical, microbiological and epidemiological material for all our readers.
The gonococcus has always been recognised as a slippery microparasite, exquisitely vulnerable to evolutionary pressures. However, it is salutary to be reminded that apparently more stable organisms can also evolve means of camouflage. Jurstrand et al (see page 337) describe an analysis of PCR and culture positive chlamydia tests in the period leading up to the identification of new variant Chlamydia trachomatis. They demonstrate that the new variant was present at detectable levels four years before its identification in 2006. In an age of increasing dependence on nucleic acid amplification tests, this is unlikely to be the last story of its kind. van Dommelen's report on the poor performance of point of care tests for chlamydia (see page 355), and Skidmore's accompanying editorial (see page 330) suggest that there is little room for complacency over the future of Chlamydia testing.
A prominent theme in this month's journal is HIV testing. This continues to be sparsely provided despite guidelines, as shown by Guy et al (see page 371) in a study of HIV negative MSM in Australian primary care. In many countries there is, rightly, an increasing emphasis on the provision of sexual health services within community settings, and of course in many rural settings there is no alternative. There is clearly much for specialists to do in ensuring that adequate sexual healthcare is provided in primary care, particularly to vulnerable and higher risk groups. A lack of routinely available, straightforwardly implementable audit measures continue to bedevil our attempts to roll out sexual healthcare more widely. Tweed et al (see page 360) present an analysis of laboratory data from a district hospital, which shows that few HIV tests are taken outside the specialist sexual health and antenatal settings. Beneath these aggregate data lies the further challenge of auditing HIV testing against its various indications, taking into account the fact that many individuals have a care pathway that—in the case of community acquired pneumonia for instance—flows between several service providers, all or none of which may offer an HIV test. In a commentary, Welz considers options for future surveillance of HIV testing (see page 364).
Peterson et al (see page 353) report a case of apparently iatrogenic transmission of Trichomonas vaginalis by a traditional healer, who initially proposed that the patient would need sexual relations with him for the “spirits to give him instructions in countering the bewitching”. This unusual case reminds us that conventional medicine and many kinds of complementary medicine are often accessed in parallel, depicts vividly the different worlds they represent in the interpretation of illness, and care of patients.
The effective use of condoms is a constant preoccupation for disease control specialists, and the paper by Rosenberger et al (see page 400) offers interesting insights into adolescent males’ early ‘exploring’ of condoms. They emphasise the role of family in learning and exploration preparatory to the use of condoms, and emphasise the importance of pregnancy prevention as a motivation to correct use in this population. This will be a useful paper for those providing education and sexual healthcare to adolescents and their parents.
A randomised controlled trial of acyclovir for genital ulcer healing and HIV shedding (see page 345) follows other disappointments in genital herpes. Phiri et al showed no difference in rates of healing in the intervention group, while among HIV co-infected individuals there was a small reduction in HIV shedding among men, but none among women.
Should we believe surveys of practitioners? Apparently not, according to Mignone et al (see page 391), who surveyed male STI practitioners, and also explored their practice using surrogate patients. 97% of practitioners self-reported advising partner treatment for an STI, but only 10% of surrogate patients reported receiving this advice. Discrepancies between self and patient reported practice have been shown in other parts of the world, and suggest that protocol driven care will be needed to ensure basic standards are met.
This month, we publish a Clinical roundup for the first time—we hope you will enjoy this, and the topical features we are interspersing throughout the journal. Do let us know what you think, and contribute to the journal by submitting miscellanea for the paper journal, and Rapid Responses on the website.
Provenance and peer review Not commissioned; not externally peer reviewed.
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