• Chlamydia

This month, we focus on the views from the far end of the swab. Two papers explore patient experiences of and attitudes to sampling for STIs. Richman et al1 report an innovative study in which they compared three different self-testing devices for women to use in self-sampling for human papilloma virus. Interesting results emerged, including women's dislike for multiple turns of a brush, and a sense that vaginal lavage was messy. These attitudes may vary across cultures, and here they varied even between rural and urban American women in a single state. Apoola et al address the longstanding fears of men about urethral swabs.2 Only a few years ago, Bradbeer and colleagues reported continuing eyewatering fears of ‘the umbrella’ in the Christmas BMJ.3 In a randomised controlled trial the authors show that swabs were associated with more discomfort than a loop. Direct urethral sampling may decline in the age of NAAT tests, but is unlikely completely to disappear, so these results are of real clinical significance.

In the age of self-testing, it is surprising to read in Howard et al's US study4 that most clinic attenders preferred to wait to see a doctor given a long wait. If turned away from a busy clinic, 41% would prefer to come back the next day rather than self-swab. These findings show patients who attend clinic want an interaction that goes beyond finding out whether they are infected. Sutcliffe et al5 explore a very different setting, sexual health services based in primary care in the UK. They show that patients typically expected either in house care, or formal referral to a specialist clinic. Although a specialised service within general practice was well regarded, many patients were disappointed by the lack of formal referral, lack of information and a perceived avoidance of sexual health matters. Recommendations for those commissioning primary care sexual health services are made.

In a review, Kaul et al set out the current state of knowledge on the role of mucosal immunity in protecting against HIV. This is a complex topic that challenges clinicians and researchers alike, and this synthesis of state of the art is very welcome. It also illuminates a paper on HIV shedding and genital ulceration, published this month.6

Male circumcision remains a hot topic, and Hallett et al provide an important update in a study which uses recent data in mathematical models.7 They conclude that the benefit to communities, and particularly to women, may be greater than previously predicted.

HIV-1 transmission patterns in the Middle East and North Africa are less well documented than in higher prevalence or higher resource settings.8 Mumtaz et al's review of molecular epidemiology evidence, and of transmission patterns brings together the evidence, showing high diversity of strains, and suggesting that established or nascent epidemics are emerging among the same higher risk groups as elsewhere in the world. The need to focus prevention work on these vulnerable populations is emphasised.

Another randomised controlled trial explores various options for technologically assisted behavioural research among adolescents in Zimbabwe.9 The authors conclude that audio-computer assisted interview (ACASI) was the best computer-based option, which also outperformed self-adminstered modalities.

As well as a trial of chlamydia screening10 which is the subject of this month's editorial,11 we have a wealth of interesting material on many topics. These include screening strategies to prevent neonatal herpes,12 intimate partner violence in sexual health clinic attenders13 and seroadaptive behaviours.14 And don't forget this month's Editor's Choice, in which Brook et al show the capacity of well constructed electronic records to expedite the audit of partner notification—a challenging topic. The story of how their records developed and were made fit for audit purposes contains lessons for all clinics entering the electronic age.15