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We live in ‘interesting times’ for better or worse. Scarcely has nucleic testing outstripped culture in the diagnosis of gonorrhoea, before it is threatened not only by the expected resistance to antibiotics, but also ‘invisibility cloak’ evolution in the form of mutants lacking the porA gene see the Editor's Choice by Ison et al.1 Having watched slow-to-adapt Chlamydia trachomatis2 evade new generation testing, the future of STI diagnosis looks increasingly uncertain. While enthusiasts continue to look forward to an age in which molecular typing helps in the characterisation of outbreaks,3 this all depends on making the diagnosis in the first place. With syphilis, we may have a little longer,4 but the perfect test still eludes us. Don't throw away microscopy and culture just yet....
HIV testing remains a challenge, with widespread reluctance to test persisting outside sexual health services in many settings. Pillay et al report the results of a promising educational intervention in a high prevalence borough of London UK, which appeared to improve HIV testing and diagnosis in participating practices.5 They propose further research in the form of a step wedge trial, and while this is to be commended, their study needs to be seen within the wider context of the many levers that are available to improve the implementation of public health interventions in general practice—including incentivization.
We report two behavioural studies, which demonstrate high potential for accelerated HIV transmission. A study of customers in alcohol serving venues in South Africa demonstrates very high rates of concurrency, and low rates of condom use outside primary partnerships, in both men and women.6 In China, a study of adolescent female sex workers reaches similar conclusions,7 with high rates of unprotected non-commercial partnerships. Such populations are important and highly vulnerable groups who have a role in potentiating the HIV epidemic, and need to be better understood and served with both upstream and downstream interventions.
We also report some early intelligence on behavioural interventions. Aghaizu et al8 report that half of a community sample of London men who have sex with men (MSM) would be willing to use Pre-Exposure Prophylaxis for HIV, and most of those likely to be in need are regularly in touch with clinical services. While the role of community prevention activities is increasingly recognised, we should not forget that clinical STI and HIV services are places where individuals at high risk of acquisition and transmission concentrate. It is important not to overlook clinical settings as a place for finding those at greatest need of interventions, wherever those interventions may then be delivered. Another report low rates of regular STI testing among MSM, and suggests the use of SMS texting to recall.9
Human papilloma virus (HPV) remains an evolving problem, and we were interested to see a study from Rakai, Uganda10 which demonstrates lower HPV shedding among circumcised men. Of course, the relationship between viral shedding and infectivity remains murky. A related issue is explored by Franco et al11 in a study which explores HPV shedding through the menstrual cycle. Like gonorrhoea, the biology and epidemiology of HPV will continue to evolve.
Finally, a letter by Desruelles et al had extensive coverage in the UK press. This preliminary report of an excess of molluscum contagiosum among patients who shaved their pubic area raises interesting questions about STI transmission.12 This is the kind of research that clinicians are well placed to initiate, and is potentially of considerable public health importance. While much research is funded by national or international research councils and charities, it is always heartening to see the origin of research in our observation and care for our patients.
Competing interests None.
Provenance and peer review Commissioned; not peer reviewed.
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