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Brief encounters
  1. Helen Ward
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    There has been concern that treatment optimism resulting from success of highly active antiretroviral therapy (HAART) could lead to complacency and unsafe sex. Stephenson and colleagues studied sexual behaviour in 420 HIV positive gay men. High levels of sexual risk behaviour were reported by both groups, with 22% reporting unprotected anal sex with a new partner in the last month. Those who were on HAART were somewhat less likely to report unsafe behaviour than those who were not on therapy. The study shows the ongoing risks for transmission from men who know that they are infected, perhaps in part explained by the finding that only one in three respondents believed that HIV positive men have more responsibility to practice safer sex than HIV negative men. More interventions are clearly needed to help reduce this risk in the future. See p 7

    IT MUST BE LOVE . . .

    “Because I loved him” was one interviewee’s reason for telling a partner that she had herpes. Other people with genital herpes were less forthcoming, particularly with casual partners. Green and colleagues interviewed 50 people attending a herpes clinic to explore factors associated with disclosure to partners. Patients were far more likely to disclose to regular partner, but even then often quite late on in the relationship. The type of relationship and anticipated response of the partner (“I think people’s conception of me would change if I said I had herpes”) were the main determinants rather than characteristics of the patient. A number of patients underestimated risks to partners, being perhaps overconfident in the effectiveness of antivirals and condoms (“it was a momentary fling using condoms, and I thought it was irrelevant”). See p 42


    Screening for chlamydia infection is cost effective in populations with a prevalence of over 3%, concluded Honey and colleagues in a review of published studies (Sex Transm Infect 2002;78:406–12), in their editorial Mehta and colleagues argue that this suggests the need for “spending money to save money”. Both articles include references to the limitations in some of the assumptions underpinning economic analyses, but conclude that the weight of evidence is balanced on the side of screening. In the UK progress towards introducing even opportunistic screening has been painfully slow. Catchpole documents the progress in the four years since the publication of the advisory group that recommended opportunistic screening of sexually active women under the age of 25. The current sticking points include lack of cost-benefit analyses, and uncertainty over the natural history of asymptomatic disease which is culture negative but positive on nucleic amplification tests. There is also concern about “logistical issues” which include the role of primary care in sexual health care. Funding is a key issue, particularly since the cost savings from screening, for example in reduced fertility treatment budgets, will not be reflected in the short term accounts of those trusts that underwrite the costs of screening. See p 3 and 4


    Should GUM clinics be run on a walk-in or an appointment basis? This is a key question for UK clinics at the moment, since increased demand for sexual health services produced a waiting list for booked appointments and increased waiting times in walk-in services. Neither system is fully satisfactory. Cassell and colleagues have evaluated the impact of a new combined system on case mix and clinical outcomes. A London GUM clinic changed from a walk-in service to one where 35% were pre-booked and 65% were allocated time slots on the same day. New patients were surveyed just before and just after the introduction of the new system. Encouragingly, the case mix did not change significantly, more patients were seen, HIV testing and partner notification rates increased, and staff preferred the new system. Although under 25s and Afro-Caribbeans were less likely to use pre-booked appointments, overall this looks like a useful combination of the two systems.See p 11

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