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Syphilis – the great pretender – is our clinical topic of the month. Its protean manifestations are seen in a case report of syphilitic periostitis,1 and two reviews explore clinical management dilemmas in HIV positive patients. The management of syphilis in HIV positive individuals has generated much heat though less light in recent years, and Blank et al's review2 sets out the inadequate state of the literature. There is a strong case for large scale randomised clinical trials, which will need firm and transparent governance in the wake of Guatemala and Tuskegee. The unreliability of non-treponemal tests in HIV infected patients with ocular syphilis is emphasised by Tucker et al,3 along with the potential to use ocular syphilis as a trigger to HIV diagnosis.
Sex between men is highlighted again this month, with studies from Africa and Pakistan painting a similarly worrying picture of the potential flow of infection between men who have sex with men (MSM), their male partners and their female partners. Shaw et al4 describe male sex workers across Pakistan, reporting low rates of condom use, long duration of sex work, and both financial and structural barriers to condom use. As the authors conservatively state, these factors—along with the 1/6 of these men who are currently married—present a ‘potentially volatile situation’. Merrigan et al report a strikingly similar picture is reported from Nigeria, with poor condom use and high prevalence of behavioural bisexuality. Policymakers everywhere need to realise that HIV prevention for MSM is a feminist issue—the risks to women, as well as to MSM themselves, are systematically lower where legal tolerance and practical prevention measures are in place.
Two studies emphasise the need for secondary strategies in HIV prevention. A modelling study by Hallett et al explores the relative utility of different scenarios of condom use to prevent HIV transmission from HIV positive men to their uninfected partners.5 While intermittent use of condoms offers little reduction in transmission, condom use based on time from last undetectable viral load can have a major effect—the study has clear messages for advising patients. Hallett et al focus on decisions to use condoms within a partnership, while Dhont et al6 draw out the implications of infertility for HIV transmission in an African setting. Secondary infertility (where there has been a previous birth) is associated with higher risk behaviour, and fertility treatment needs may be an important structural element of an HIV prevention strategy.
HPV remains a hot topic, with a modelling study7 suggesting that the type 16 appears to have lowest type-specific effectiveness of vaccine—so that trends in type 6 and 11 associated genital warts may not be a reliable guide to the public health impact of quadrivalent vaccine. A Canadian study demonstrates strong societal preference for vaccination of both genders, which may relate more to views on equity than the likely effectiveness of the vaccine.8
It is very heartening to see research on partner notification emerging from Bangladesh. Alam et al9 report that a single session of counselling improved partner notification rates from 27% to 37% in a quasi randomised trial. In an intriguing clinical study, Horner and Taylor-Robinson10 report an association between Mycoplasma genitalium and balanoposthitis, speculating on its possible relation to HIV transmission.
Competing interests None.
Provenance and peer review Not commissioned; not externally peer reviewed.