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Many of our readers will remember a period when the HIV care community collectively woke up to patients' ongoing need for STI testing and diagnosis. A number of published studies and audits showed that STI testing in this population was limited and sporadic, resulting in efforts to establish regular routines of testing. Since then, the need has become arguably greater, particularly for men who have sex with men (MSM): syphilis has regained its place as a commonly diagnosed condition, and lymphogranuloma venereum has become endemic in this populations, in a number of urban settings. But just how high does testing need to be, and how do we target testing? Hawkes et al1 present an interesting study from Toronto, demonstrating that a near-doubling of STI testing was associated with a decline in positivity and minimal change in overall diagnosis. Stephen Berry reflects on these findings in an accompanying editorial2 which will interest both clinicians and commissioners of services. This reminds us of an Australian study by Wilson et al3 in 2010, which argues that over-screening of sex workers to meet legislative requirements was wasteful of resource. On a related note, Fifer et al4 report on the limited literature about testing with nucleic acid amplification tests for gonorrhoea in low prevalence settings. They warn of the likely high number of false positives—a real concern as these tests are being rolled out without targeting.
Don't we all wish we could tell the future? In this issue, Gamagedara et al5 argue that we can—or at least that clinic attendances in different patient groups can be predicted by factors including temperature, morning or afternoon sessions, and recent holiday periods. They argue that this information can be used in advance to allocate resource and expertise to busier periods or quieter ones. Is this something we should all be doing?
Condoms, condoms, condoms. We probably talk about them badly, and need to understand better who is at risk of condom error or failure. Condom failures and incomplete use are explored by Hernandez-Romieu et al, who present data on the particular vulnerability of black MSM in the southern USA to condom failure.6 This is particularly worrying given the very high incidence of HIV in this group. Given the powerful protection offered by correct and successful condom use, and its applicability to resource rich and resource poor countries, it is time for a scaled up research programme on interventions to improve condom use.
Partner notification (PN) is a difficult topic to research, as it is so challenging to obtain observational data both on the PN consultation, and the interaction between patients and their partners. Knight et al7 are to be commended on a study which describes the choices patients actually made in contacting their partners. They show that while an overwhelming proportion of patients chose to contract partners themselves, electronic communications were more likely to be chosen by people with syphilis, or with more sexual partners. On a related note, there is much commentary on the role of the internet in sex seeking. Abara et al8 present a community survey of MSM, exploring how they used the internet in relation to their sexual risk behaviour. They emphasize the importance of well articulated operational definitions of “internet sex seeking” in such research, if it is to be meaningful in informing services.
Mucosal cytokines and their relation to STI infection status is fascinatingly discussed by Masson et al.9 Chlamydia and gonorrhoea in particular were associated with high levels of cytokines,9 but this did not correlate with plasma levels. The science of cytokines is still being worked out, and far from an intervention. But its potential importance in STI control is borne out when we consider the extraordinarily high burdens of STI still borne by many populations in the developing world, which are also reported this month by Abdool-Karim et al,10 Lurie et al11 from South Africa, and Geraets12 from Suriname.