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Chlamydia remains a contested field, with many unanswered questions about its natural history and the benefits of screening. In order to assess the value of screening, we need to deliver chlamydia tests at scale (and of course measure their outcomes). Delivery was the task faced by McNulty et al1 who report a randomised controlled trial of a complex intervention designed to increase chlamydia testing in UK general practice i. This interesting study uses the controversial Zelen design, in which participants (practices and patients) are not informed that they are taking part in a trial. This approach has been defended,2 but remains controversial. Interestingly, McNulty et al showed a significant effect of the intervention, but a small absolute change in uptake. Miller and Nguyen3 reflect on this trial in a thoughtful accompanying commentary. On a related note, a modelling study by Low et al4 addresses the relevance of partner notification estimates to randomised trial design for STIs.
Partner notification is in its own right another complex field for evaluation. “Suggest a test” is an online tool implemented and evaluated by Götz et al in the Netherlands.5 It is an online service to which clinics provide access, and while the proportion of clients using this service was small, engagement by partners in this group reached useful levels. An editorial by Gilbert and Hottes6 reflects on the place of “Suggest a test” in the context of rapidly changing communication technologies – including the need to develop complementary, and not necessary alternative, approaches to partner notification.
Several articles, and from a range of settings, explore sex workers and their clients. As concerns develop about the spread of anti-homosexuality legislation in Africa, and anti-prostitution debates take new forms in Europe, it is essential that empirical evidence continues to inform policymaking. McKinnon et al7 report high incidence and prevalence of HIV in men who have sex with men (MSM) and male sex workers, exploring their place, prevention needs and vulnerability in the HIV epidemic. Some analogous findings – including high levels of bridging with the heterosexual population – are reported by Bayer et al from Peru,8 drawing attention to the need for policymakers to understand and address structural features of societies which determine the structures of vulnerability and risk. The theme of sex work, this time in China, continues in a study of male clients of female sex workers by Zhang et al,9 while Santos et al10 address the wider issues of syndemics in MSM, and Holt et al assess HIV/STI testing in Australian MSM.11
Medicine is ever tempted by the mirage of the “magic bullet” which will solve all our problems, though a technical fix. A Notoriously, an example was the impact of antibiotics – William Stewart, Surgeon General, saw 1967 as time to “close the book on infectious diseases” – while we await the verdict of history on Treatment as Prevention for HIV. A more modest utopian dream is offered by point of care diagnostics, which as I often point out have been with us for some time in the form of gram stains and dark ground microscopy. These almost historical tests had their limitations, and so do the modern generation of tests. Hurly et al12 present an evaluation of chlamydia point of care tests in a low resource setting, concluding that their performance is well below that stated by the manufacturers. Van Der Pol13 addresses the practical and policy issues in an accompanying editorial.
Spring is traditionally the time for lovers and romance, celebrated around the world as a time of renewal and fertility. From the South East of England I look forward to making new friendships and renewing old ones at conferences of the British Association of Sexual Health and HIV and the American STD Association in the coming months. It is always a pleasure to make meet readers from around the world, and to hear your views on what the journal is doing well, what we could do better, and where we should be going next.
Competing interest None.
Provenance and peer review Commissioned; internally peer reviewed.