If your required knowledge of Scotland is limited to “Tartan tourism” and our inferior national football team, you may wish to stop now. If, however, you wish to find out more about how Scotland is tackling its poor sexual health, read on.

Scotland faces similar challenges to much of the United Kingdom with high levels of unwanted conception and rising STI and HIV rates. The population of around five million is concentrated in the central belt of Scotland with relatively poor access to sexual health services in many areas. Despite this, there has been a dramatic rise in diagnosed genital chlamydia infection, especially in those under 25 years old. There were 11 917 laboratory diagnoses between January and September 2004, compared with 10 124 during the same period in 2003. Although some of the increases in chlamydia are related to changes in sexual behaviour as elsewhere in the United Kingdom, testing has become more easily accessible owing to developments such as the Sandyford Initiative in Glasgow and the new West Lothian outreach clinics, which both provide integrated community based services. Self testing for chlamydia has been promoted in Aberdeen and by Healthy Respect, the sexual health demonstrator project, in Lothian. Healthy Respect is currently evaluating the impact of postal chlamydia testing. The kits (see fig 1) have been distributed in community sites such as pharmacies and record shops as well as in health settings. Other STIs including gonorrhoea continue to rise in Scotland. There is also an ongoing syphilis outbreak with a 146% increase between 2003 and 2004, predominantly in men who have sex with men. Fast track outreach testing is being performed in Glasgow to reach homosexual men who might not otherwise use conventional settings. There are peer supported services specifically for men who have sex with men in many areas, notably the Steve Retson Project in Glasgow and Man Friday in Grampian. There has been significant integration of genitourinary medicine with family planning and reproductive health in Scotland, which has helped establish high quality services, notably for young people but also for other socially excluded populations including the homeless, those from black and ethnic minority groups, and people with physical or learning disabilities.

Many associate HIV in Scotland with injecting drug users, given the large cohort infected in Edinburgh in 1984; however, sex between men cumulatively accounts for the largest proportion of the 4128 HIV cases diagnosed to date. Owing to the rapid implementation of needle exchanges and methadone projects, the number of new Scottish HIV cases acquired by needle sharing is now in single figures each year. Despite this, there remain a significant number of HIV positive drug users with hepatitis C co-infection. Recently, there has been a large rise in the number of heterosexuals infected abroad being treated in Scotland. This, coupled with the successful implementation of opt out testing in GUM clinics, has resulted in a rise in new HIV diagnoses in the past 3 years. The average in the 1990s was 150–180 new cases per year. There were 258 new HIV diagnoses in 2003 and from January to September 2004 there have already been 274 new HIV diagnoses.

BASHH Scotland is well supported and has been ably led by Dr Andy Winter in its first year. Achievements have included the delivery of a secure web based data collection for GUM clinic coding. With pump priming money from the Scottish Executive, all clinics acquired new computers and the new “STISS” (STI Surveillance Scotland) is now live. The STI Foundation course is also thriving in Scotland with 617 delegates attending the first 13 courses including 388 doctors (167 of whom were GPs) and 165 nurses. Much effort has been put into supporting sexual health workers from all disciplines, particularly in developing competencies and training. Several new genitourinary medicine consultant led services have been established in Scotland including in Paisley, Borders and Ayrshire; however, recruitment of staff is a challenge for smaller units despite the high quality of life on offer in Scotland.

By the time you read this, I hope that the Scottish Executive Health Department will have released their implementation plan and resources for the Sexual Health and Relationships Strategy. The draft strategy, produced by an expert reference group, was presented to the Scottish Executive in November 2003 and was followed by a period of public consultation. The strategy takes a broad societal approach with sections on promoting positive sexual health, education, mass communications, leadership, and accountability as well as service provision. Inevitably, this has generated headlines (often misinformed) and public debate orchestrated by those who believe that sexual activity should be confined to heterosexual marriage. The approach of BASHH Scotland has been to share best practice and ensure patient access is maintained (often by very busy drop-in services). The message given to the Scottish Executive and others is that GUM has responded positively to capacity and case mix pressures by modernising and delivering the best possible models of service, often in partnership with others. So far there has not been significant investment in Scottish GUM using either HIV cash or new funding stemming from the Sexual Health Strategy in England and Wales. Therefore, implementation of the Scottish Strategy is eagerly awaited.