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OBJECTIVE—To determine, within a representative population group of men and women, whether alteration of the lipid profile might underlie the reported association between Chlamydia pneumoniae and ischaemic heart disease. DESIGN AND SETTING—Cross sectional survey in an area with a high incidence of ischaemic heart disease. SUBJECTS—400 randomly selected participants in the World Health Organisation MONICA project's third population survey in Northern Ireland. MAIN OUTCOME MEASURES—Stored sera were examined by microimmunofluorescence for IgG antibodies to C pneumoniae at a dilution of 1 in 64. Mean total and high density lipoprotein (HDL) cholesterol were compared between seropositive and seronegative individuals with adjustment for age, measures of socioeconomic status, smoking habit, alcohol consumption, body mass index, and the season during which blood had been taken. RESULTS—In seropositive men, adjusted mean serum total cholesterol and HDL cholesterol were 0.5 mmol/l (9.2%) higher and 0.11 mmol/l (9.3%) lower, respectively, than in seronegative men. Differences in women did not achieve statistical significance, but both total cholesterol and HDL cholesterol were higher (3.6% and 5.8%, respectively) in seropositive than in seronegative individuals. CONCLUSIONS—There is serological evidence that C pneumoniae infection is associated with an atherogenic lipid profile in men. Altered lipid levels may underlie the association between C pneumoniae and ischaemic heart disease. Keywords: epidemiology; lipids; cholesterol; ischaemic heart disease

Objectives: To analyse trends in rates of genital chlamydial infection and ectopic pregnancy between 1985 and 1995 in a county in Sweden. Setting: Uppsala county where screening for chlamydial infection, treatment, and contact tracing has been widespread and where ectopic pregnancies are recorded. Methods: Rates of chlamydial infections and ectopic pregnancy between 1985 and 1995 were calculated for women aged 20-39 years. Poisson and linear regression were used to examine the association between the risk of ectopic pregnancy and the current rates of chlamydial infection and rates of chlamydial infection from up to 5 years earlier. Main outcome measures: Rates of chlamydial infection per 100 examinations, rates of ectopic pregnancy per 1000 pregnancies, rate ratios and 95% confidence intervals for an increase in chlamydial infections of 5 new cases per 100 examinations. Results: 103 870 cervical samples from women aged 15-39 years were analysed; 5648 (5.4%) were positive for chlamydia. 51 630 pregnancies were analysed; 930 (1.8%) were ectopic. Both rates declined over time. For women aged 20-24 years there was a strong correlation between the rate of ectopic pregnancy and the rate of chlamydial infection in the same year (r=0.93, P Conclusions: Declining rates of genital chlamydial infections have probably led to a fall in the rate of ectopic pregnancies. The timing of the decline in the rate of ectopic pregnancies varies with age. Among young women falling rates of chlamydial infection have been accompanied by an immediate reduction in the rate of ectopic pregnancy. Key messages The effect of measures to diagnose and treat genital chlamydial infections on the risk of ectopic pregnancy was examined in a county in Sweden Rates of chlamydial infection and ectopic pregnancy both declined between 1985 and 1995 Chlamydial infections seem to be the main cause of ectopic pregnancy in young women; the risk of ectopic pregnancy decreased concurrently with the decline in chlamydial infections In older women the associations were less pronounced

OBJECTIVE—To study possible associations between coronary heart disease and serological evidence of persistent infection with Helicobacter pylori, Chlamydia pneumoniae, or cytomegalovirus. DESIGN—Population based, case-control study, nested within a randomised trial. SETTING—Five general practices in Bedfordshire, UK. INDIVIDUALS—288 patients with incident or prevalent coronary heart disease and 704 age and sex matched controls. RESULTS—High concentrations of serum IgG antibodies to H pylori were present in 54% of cases v 46% of controls, with corresponding results for C pneumoniae seropositivity (33% v 33%), and cytomegalovirus seropositivity (40% v 31%). After adjustments for age, sex, smoking, indicators of socioeconomic status, and standard risk factors, the odds ratios (95% confidence intervals) for coronary heart disease of seropositivity to these agents were: 1.28 (0.93 to 1.75) for H pylori, 0.95 (0.66 to 1.36) for C pneumoniae, and 1.40 (0.96 to 2.05) for cytomegalovirus. CONCLUSIONS—There is no good evidence of strong associations between coronary heart disease and serological markers of persistent infection with H pylori, C pneumoniae, or cytomegalovirus. To determine the existence of moderate associations between these agents and disease, however, larger scale studies will be needed that can keep residual confounders to a minimum. Keywords: ischaemic heart disease; Helicobacter pylori; Chlamydia pneumoniae; cytomegalovirus

Little is known of the inflammatory characteristics of acute infections of the respiratory tract caused by virus and unusual bacteria such as Chlamydia pneumoniae. A case is reported in whom inflammatory indices in sputum were used to investigate, for the first time, the airway inflammation during an episode of acute bronchitis caused by C pneumoniae. The patient presented with a dry cough of five days duration. C pneumoniae was identified by polymerase chain reaction (PCR) in a nasopharyngeal swab collected on day 5. Virological studies were negative. Clinical and inflammatory indices in induced sputum were measured on days 6, 8, and 11. The cough cleared spontaneously by day 11. Forced expiratory volume in one second was normal throughout. Sputum findings identified intense airway inflammation characterised by increased total cell and lymphocyte counts followed by an increase in neutrophils and a decrease in the CD4/CD8 ratio, activation of CD8 lymphocytes, and exudation as indicated by an increase in fluid phase fibrinogen. These observations suggest that sputum might be useful to monitor an inflammatory/immune response of the airway in acute infections.

A controlled prospective study was made of a group of patients with chronic bronchitis, in which serum antibodies against a group of viruses and Mycoplasma pneumoniae were estimated at regular intervals. Sixteen significant rises in antibody titre were shown, of which eight were associated with clinical acute exacerbations of bronchitis. In individual patients no correlation was found between the number of acute exacerbations or the aetiological agent and persistent change in ventilatory function as expressed by the F.E.V.(0.75).This study was compared with the results of a previous parallel investigation of the same patients done to study the significance of rhinovirus infections. In the present investigation 12% of the acute exacerbations were associated with the 11 agents tested compared with 14% associated with rhinoviruses in the earlier work.

Objectives To measure the time taken to recall and treat patients with untreated Chlamydia attending a sexual-health clinic before and after the introduction of electronic patient records (EPR). Methods 52 consecutive qualifying patients were identified for January to March 2007 (paper case records) and 2009 (EPR). For each, the patient time intervals were measured between each of following dates: first attendance, first positive result received, first attempted patient contact and attendance for treatment. Results Between 2007 and 2009, the median time taken to treat a patient after receipt of a positive Chlamydia result fell by 11.5 days (median 15 days in 2007, 3.5 days in 2009). The time between first attendance and treatment was reduced by 9.5 days (median 21 days in 2007, 11.5 days in 2009) despite results taking 2 days longer to arrive in 2009. The proportion of patients treated within 2 weeks of a positive result rose from 38% in 2007 to 94% in 2009. Compared with paper notes, EPR decreased the time to recall, by eliminating three time-delaying patient recall processes. By ensuring more accurate patient recall information, EPR also lead to a higher proportion of patients successfully recalled by telephone (26/44, 59% vs 46/52, 88% in 2007 and 2009 respectively), leading to earlier treatment. Conclusions The ‘time to treat’ interval was dramatically reduced following the introduction of EPR. Clinics using paper notes should consider switching to EPR as a means of improving STI recall efficiency.

While scanning De Baetselier and colleagues’ article evaluating an enzymatic Chlamydia trachomatis (CT) point-of-care assay (POC), I was struck by a feeling of deja vu.1 They found the BioChekSwab Rapid Test performed poorly, missing all nine infections detected by PCR. This reminded me of a paper by Moi in 2007 reporting the very poor performance of a POC for CT, HandiLab-C.2 Reading further, I realised this was not coincidence. The two assays seemed to use the same technology. BioChekSwab Rapid Test seems to be an updated HandiLab-C test that was widely available about 10 years ago. Sold in at least 17 countries, it had a CE mark with approval for POC professional use and over-the-counter sale (meaning self-test).Web1 In 2006, workers at the National Chlamydia Screening Programme, concerned about use of the test in England (it was for sale in pharmacies and supermarkets), asked me to speak about chlamydia diagnostics at their annual meeting. My talk emphasised nucleic acid amplification tests (NAATs) for CT diagnosis and warned about using HandiLab-C because the technology was not new and there were no reproducible clinical data supporting its use despite the company’s claims. Within a year, the Moi paper appeared stating that the HandiLab-C assay was not what it claimed. Subsequent trials confirmed that, finding sensitivity of only 12.5% and 19.4% in two clinics in the Philippines, and 12% in an STD clinic in the Netherlands.3 ,4 I was familiar with the HandiLab-C technology because in the 1980s Diversified Diagnostics Inc. (DDI) had a similar assay ‘MicroZyme the Easy Test’, claiming sensitivity of 96% and specificity of 97.9% for CT detection.Web2 It was described as the only totally biochemical test system; easy to perform; only 10 min to get a result. The procedure was collect …

Understanding the burden of Chlamydia trachomatis in populations is based primarily on studies of prevalence of current infection, measured using sensitive and specific nucleic acid amplification tests on genital or urinary specimens. Such studies have produced widely varying results, but most have emphasised the high prevalence in young, sexually active women with many fewer studies in men. 1 Studies have frequently been based on clinic populations, which suffer from problems of selection bias (toward those at highest risk) and limited demographic and behavioural data. The few studies based on random and representative population samples have generally demonstrated lower prevalence and increased risk linked to increasing numbers of sexual partners. 2 Studies of Chlamydia incidence in population samples are few and far between. Data from national surveillance programmes consistently show rising rates of diagnosed infection in most developed countries over the last decade. But this cannot measure true incidence of infection because they are biased by the introduction and wider spread use of new sensitive tests leading to increased diagnosis of asymptomatic infection. All these studies measure current infection. They cannot account for past exposure or measure cumulative risk of infection over time, that screening programmes aim to minimise. In this issue, Paavonen et al report on C. trachomatis antibody seroprevalence in a stratified probability sample of 8000 sera from a large Finnish population serum bank.2,3 Participants were women under 29, having at least two pregnancies. The paper illustrates an approach which could potentially be used more widely. The paper assesses prevalence of past exposure to genital C. trachomatis and explores changes over time by comparing age specific prevalence at different time points.

The paper by Hopkins et al suggests that repeat testing for C trachomatis (CT) and N gonorrhoeae is unnecessary.1 This issue has long been debated2–4 and currently, with many laboratories having to reduce costs, the view put forward in this paper seems attractive. We would, however, like to make the following points. Repeat testing for CT using the same platform is not recommended for the purpose of confirmation. Confirmation must be by a second …

We read with interest the recent paper by Blasi et al which showed that Chlamydia pneumoniae infection is associated with higher rates of exacerbation and airway microbial colonisation in patients with COPD.1 We have prospectively studied patients in the East London COPD study with daily monitoring using diary cards to detect COPD exacerbation defined using the same criteria.2,3 Serum microimmunofluorescence (MIF) immunoglobulin G (IgG) titres for C pneumoniae were measured in 110 patients (FEV1% 41.7 (18.4)) with stable COPD during 1 year with simultaneous estimation of plasma fibrinogen and serum interleukin 6 (IL-6); 26% of the patients had IgG titres of ≥1 in 16 (fig 1). High C pneumoniae IgG titres were not related to FEV1 % predicted, exacerbation frequency, plasma fibrinogen, or serum IL-6 levels. In their paper Blasi et al did not report whether there was a relation between MIF titres and exacerbation frequency. Blasi and colleagues found that 43% of patients when stable were positive for C pneumoniae by DNA polymerase chain reaction (PCR) using peripheral blood mononuclear cells (PBMCs). At exacerbation they have only shown data for the 34 (of 61) who consented to the antibiotic trial and all 34 were positive for C pneumoniae . In our study a further 33 patients (FEV1% 39.8 (16.3)) were simultaneously sampled using nasopharyngeal aspirates and induced sputum when stable and during 43 COPD exacerbations. We found no C pneumoniae using a nested reverse transcriptase PCR adapted from Cunningham et al 4 …

Objectives In this paper we examine Chlamydia trachomatis testing in settings other than genitourinary medicine (GUM) clinics, focusing on the factors associated with chlamydial infection and with postal testing. Methods Analysis of tests collected from young people aged 13–25 years ( n = 4475) between May 2001 and June 2004 via postal testing kits, at a local sexual health clinic, and at further education colleges in Lothian, Scotland. Results 84.8% of the testers were female and 15.2% were male. 84 men (12.3%, 95% CI 10.1–15.0) and 403 women (10.6%, 95% CI 9.7–11.6) tested positive. The odds of a positive result was nearly doubled for postal and clinic testers, relative to college testers; and increased by 70% for 16–19-year-olds, compared with 13–15-year-olds. Postal testing was the main source for men (80.2%) while 46.1% of women used postal and 48.1% used clinic testing. Postal testing was significantly associated with age, sex and National Health Service (NHS) board area, with odds increasing with age, and lower odds among females than males, and among Lothian residents than those outwith this NHS board area. Conclusions Substantial chlamydial infection was apparent among the young people in this study and positivity rates were highest among postal and clinic testers and those in the 16–19-year age group. While postal kits were the main source for men, and should be used to target them, the combination of this approach with continuing screening programmes in clinic settings would be most effective at targeting those most at risk.

Objectives: Knowledge concerning genital Chlamydia trachomatis infections in eastern Europe is scarce. Data on the legal aspects, epidemiology, diagnosis, and treatment of the infection have never been collected, summarised, and presented to the international scientific community. The aim of this study was to present the current situation on the main aspects of chlamydial infections in the countries of eastern Europe. Methods: Written questionnaires concerning legal aspects, epidemiology, diagnosis, and treatment of the infection were distributed among national STI operating administrators as well as researchers who had presented papers at earlier meetings of European chlamydia or STI societies. Results: Most of the countries have not legalised reporting of chlamydial infections and in those who have done so, the quality of the reporting system is poor. Contact tracing is mostly done on a voluntary basis. Reported chlamydia incidence varies from 21 to 276 per 100 000 inhabitants. The most commonly used diagnostic test remains the direct immunofluorescence test; however, some tendencies towards nucleic acid amplification are in evidence. Diagnostic services are paid for by the patient himself, while treatment in many countries is partially or completely covered by public insurance. Conclusions: This is the first report summarising data concerning the situation on C trachomatis infections in eastern Europe. The reporting system and diagnosis of C trachomatis infections remain suboptimal, which allows neither control of the epidemiological situation nor optimal treatment of the patients. The most urgent work currently necessary is the education of professionals and the general population. enital infections caused by Chlamydia trachomatis and the important sequelae of these infections are well documented in the developed Western countries, with articles in which the epidemiology, diagnosis, treatment, and other management issues related to chlamydial infections are discussed. During the initial period of reorganisation of the healthcare systems in the “newborn” countries, after the collapse of the USSR, questions concerning sexual health were mostly ignored. During national as well as international meetings, healthcare administrators did not address issues concerning sexually transmitted infections (STIs). One reason for this was that for many years specialised institutions managed tuberculosis as well as HIV and other STIs. Furthermore, there were no internationally available publications discussing STI issues of this region. Moreover, without the epidemic of syphilis, the situation would probably have remained unchanged. However, the alarming syphilis situation resulted in several publications in international journals and World Health Organization activities contributed to the presentation and analysis of the epidemic.

This paper summarises the results of the R0 equation in sexually transmitted infection (STI) repeaters in Manitoba, Canada, in the early 1990s, with both concurrent and more recent descriptions of sexual networks in the same population. The research presented provides empirical network and sex partner data to refine definitions of sexual networks and core groups in phase IV epidemics. New challenges for both practice and research are also discussed.

Over the past three decades, research focus on the development and evaluation of behavioural interventions aimed at reducing the spread of sexually transmitted infections (STIs) including HIV has expanded considerably. Individual, couple and group level interventions aimed at improving condom use, HIV testing, linkage to care and retention, medication adherence, partner counselling and referral services, and decreasing number of partners have been developed and evaluated for many subpopulations.1–5 The interventions have been evaluated among African–Americans, Asian and Pacific Islanders, drug users, heterosexual adults, high-risk youth, Hispanic populations, men who have sex with men, people living with HIV, STI clinic patients, and transgender populations. However, despite their availability, behavioural interventions are inadequately utilised, and evidence of their population level impact is lacking. In this paper we discuss issues related to the utility of behavioural interventions, including questions around feasibility of implementation, scale-up and maintenance, and suggest new directions for planning, implementation, evaluation and continuous improvement of social and behavioural interventions in the context of STI and HIV prevention programmes. Most evidence on the efficacy of behavioural interventions is based on self-reported behaviour, and change in self-reported behaviour, as outcome. Assessment and reporting of sexual behaviour is subject to ascertainment and reporting bias.6 Such bias is particularly important in the context of behavioural intervention trials, because the intervention directly manipulates the desirability of certain reported behaviours, and subjects cannot be effectively blinded to the intervention. For behavioural intervention trials, STI and HIV incidence are the outcome measures of greatest interest. Unfortunately, trials that use STI and HIV incidence as outcome measure have not shown high levels of efficacy. Of the seven randomised controlled trials of behavioural interventions that measured HIV incidence as outcome, none were found to be efficacious.7 Of …

Objective—To review the literature for evidence that chronic infection with Chlamydia pneumoniae is associated with atherosclerosis and acute coronary syndromes. Data sources—MEDLINE and Institute of Science and Information bibliographic databases were searched at the end of September 1998. Indexing terms used were chlamydi*, heart, coronary, and atherosclerosis. Serological and pathological studies published as papers in any language since 1988 or abstracts since 1997 were selected. Data extraction—It was assumed that chronic C pneumoniae infection is characterised by the presence of both specific IgG and IgA, and serological studies were examined for associations that fulfilled these criteria. Pathological studies were also reviewed for evidence that the presence of C pneumoniae in diseased vessels is associated with the severity and extent of atherosclerosis. Data synthesis—The majority of serological studies have shown an association between C pneumoniae and atherosclerosis. However, the number of cases in studies that have reported a positive association when using strict criteria for chronic infection is similar to the number of cases in studies which found no association. Nevertheless, the organism is widely found in atherosclerotic vessels, although it may not be at all diseased sites and is not confined to the most severe lesions. Rabbit models and preliminary antibiotic trials suggest that the organism might exacerbate atherosclerosis. Conclusion—More evidence is required before C pneumoniae can be accepted as playing a role in atherosclerosis. Although use of antibiotics in routine practice is not justified, large scale trials in progress will help to elucidate the role of C pneumoniae. (Heart 1999;81:232‐238)

The introduction into clinical practice of nucleic acid amplification tests (NAAT) with high sensitivity and specificity has significantly improved the diagnosis of patients infected with Chlamydia trachomatis. One of the advantages of NAAT is their high performance when used on urine samples, which makes them ideal for screening programmes in non‐clinical settings.1 According to the manufacturer's instructions for specimen collection before testing by the Cobas Amplicor Chlamydia trachomatis/Neisseria gonorrhoeae (CT/NG) test the patient must not have urinated during the previous 2 hours. As a literature search did not find any publications on the time since last voiding urine and the performance of the Cobas Amplicor CT/NG test we inquired of the manufacturer (Roche) how this time interval was determined. Roche were also unable to find any papers on how the time elapsed between urine collection and the previous void affects the detection of chlamydia by their test. In addition, there are no “in‐house” data relating to this. The selection of 2 hours as the minimum time between specimen collection and previous void dates back to before 1993 and was chosen during the development of the original Amplicor CT test, as this seemed a reasonable amount of time for the urethra to be repopulated with shedding cells. The test performance cited in the product insert is for samples where at least 2 hours elapsed (Brayshaw, molecular diagnostics sales manager, Roche Diagnostics, personal communication, 2004). A subanalysis of a study on 23 men with chlamydial infection (including seven with less than 2 hours of voiding interval) did not show any change in the performance of ligase chain reaction on urine specimens of men with interval since last voiding of less than 2, 4, and 8 hours, respectively.2 As an interval of 2 hours since last voiding urine before providing a urine specimen for chlamydia testing may be a problem, and act as a barrier to testing, for a proportion of patients in clinical and non‐clinical settings, it is important to investigate if this is a significant factor in the performance of NAAT. The aim of this study was to investigate the effect of voiding interval on the performance of chlamydia PCR testing by examining the difference in the positivity rate of chlamydial infection between urine samples obtained less than 2 hours and those obtained 2 hours or longer after last urination.

Background/introduction Mobile Phone ‘apps’ such as grindr© are becoming a more frequent and convenient way to meet sexual partners and may be a reason why sexually transmitted infections(STI) are increasing in MSM. Methods From November 2015 to February 2016, a paper survey was distributed to MSM attending local sexual health services on acceptability of local service, including use of mobile phone applications to meet sexual partners. National Student Pride also used an online version of the survey. Results 1186 MSM were included in the analysis of this survey. The median age was 26.8 years (18–89). 1026/1186 (86.5%) self-identified as gay, 108/1186 (9.1%) bisexual and 34/1186 (2.9%) straight. 918/1186 (77.4%) were HIV-negative, 42/1186 (3.5%) HIV-positive, 188/1186 (15.9%) never tested, and 38/1186 (3.2%) unknown status. 200/1186 (16.9%) of respondents reported a bacterial STI within the past 12 months: 116/1186 (9.8%) had gonorrhoea, 96/1186 (8.1%) chlamydia and 26/1186 (2.2%) syphilis. Reported use of grindr© was: 372/1186 (31.4%) more than once/day, 168/1186 (14.2%) more than once/week 124/1186 (10.5%) more than once/month. Those who used grindr© more than once per day reported having had gonorrhoea (62/372:16.7%), chlamydia (50/372:13.4%) and syphilis (16/372:4.3%) in the past 12 months. 80/116 (70.0%), 64/96 (67%) and 16/26 (62%) MSM who reported having gonorrhoea, chlamydia and syphilis in the past 12 months reported using grindr© at least once a month. MSM were significantly more likely to report having gonorrhoea and chlamydia (but not syphilis) in the past 12 months using grindr© at least once per month compared to never using grindr(t-test = 2.79; p = 0.003), (t-test = 2.20; p = 0.028), (t-tst = 0.58; p = 0.565). Discussion/conclusion Use of the mobile phone application grindr© is associated with acquisition of bacterial STIs. Public health interventions to reduce STI rates in MSM should include using appropriate social media.

Background/introduction Equivocal NAAT results for Chlamydia and gonorrhoea (GC) cause treatment dilemmas for health professionals as there are no definitive management guidelines. Debate continues whether to rescreen and treat patients with equivocal results or rescreen the patient and await results before treatment. Aim(s)/objectives To investigate rescreening tests for equivocal results and establish when patients should be offered treatment. Methods A retrospective study of equivocal results from 2 GUM clinics between November 2013 and May 2014, and a third clinic between March 2010 and May 2014. HIV positive patients’ results were included. Paper notes or electronic systems were examined. Data was collected using a standardised proforma and analysed using excel software. Results 76 equivocal results (2.2% of positive results) were investigated. 62 patients (83.8%) attended recall appointments, 36 patients (58.0%) were offered treatment and rescreened, 14 (22.6%) were rescreened and awaited results prior to treatment and 2 patients (3.2%) were treated with no retest sent. 8 patients (16.1%) were treated due to a positive GC result at a second site alongside the equivocal result. Of the 54 equivocal results re-tested, 3 (5.6%) were positive and all of these resulted from equivocal GC tests (19 rescreened). All 35 rescreened equivocal Chlamydia tests were negative. Discussion/conclusion There is currently variation in how clinicians are managing equivocal results. The findings suggest that initiating treatment for Chlamydia before rescreening may result in over treatment. GC equivocal results are more likely to be positive on re-testing, thus clinicians should have a lower threshold for treating these at the time of rescreening.

Introduction Self-taken samples increase testing for Chlamydia and Gonorrhoea in high-risk asymptomatic populations including HIV-outpatients. Women are offered self-taken vaginal samples; heterosexual men first-pass urine and MSM self-taken rectal and throat samples and first-pass urine. The acceptability of this method of testing is not well understood. Methods An anonymous paper survey was offered to all patients attending outpatient-HIV clinic June–July 2014. Data collected: age, gender, ethnicity, sexual-orientation; perceptions of self-taken samples; whether they tested that day, and why. Results 121 surveys were returned. Median age = 45(20–69)years; 86% male; 68% white British; 73% homosexual. 61/121(50%) rated STI screening as ‘very important’, 48/121(39%) as ‘worthwhile’: 117/121(96%) rated offering self-taken samples in routine HIV clinic as appropriate. 86/121(71%) found the instructions ‘easy’ to follow and 4/121(3%) ‘difficult’. 78/121(64%) said that they thought that self-taken samples are as reliable compared to clinician-taken and 10/121(8%) thought they were more reliable. 60/121(50%) said self-taken samples were as comfortable as clinician-taken; 30/121(25%) said more comfortable. 33/121(27%) responders did self-sampling that day; 78/121(64%) did not. Participants’ reasons for accepting self-taken samples included: ‘It’s easier/quicker than going to a GUM clinic’ (37%); ‘I prefer doing the swabs myself’ (25%). Reasons for not self-sampling included: ‘I haven’t had any sex since my last sexual health screen’ (26%); ‘I was not offered a STI screen today’ (20%); ‘I prefer to go to a GUM clinic’ (16%). Conclusions The self-swab STI screens are acceptable to patients attending HIV outpatients’, and are perceived as being as reliable and as comfortable as clinician-taken samples.

Realising the individual and potential population benefits of any chlamydia screening programme depends on good case management. At the very least, this should include the provision of effective and timely antibiotic treatment, finding and treating infected sexual partner(s), and the provision of condoms and safer sex advice.1–3 The papers in this issue and several previously published studies lead us to question whether retesting of people who test positive should also be a routine part of clinical practice. Several countries already recommend retesting 3–12 months after a chlamydia diagnosis.4–7 In England, the National Chlamydia Screening Programme (NCSP) recommends that sexually active young adults be tested annually and on change of sexual partner, but there is no recommendation to routinely retest positives more frequently.3 Should there be? The clinical arguments for retesting are strong. First, we know from prospective8–11 and passive12 ,13 follow-up studies that individuals who test positive for chlamydia are at considerably higher risk of subsequent chlamydia infection than those who test negative. Retesting could therefore lead to considerably greater numbers of infections being diagnosed and treated. In a …

Background With traditional specialist sexual-health services overstretched, community pharmacies have been deployed to provide chlamydia testing. We have undertaken a systematic-review to estimate prevalence of chlamydia infection among those screened for chlamydia in community pharmacies. We also reviewed the feasibility/acceptability of this service. Methods Systematic searches were conducted in electronic databases and grey literature was solicited from experts. Data were extracted on study population, sample size and prevalence of chlamydia to report pooled proportion of chlamydia infection using random effect model. Results 8 papers and reports which contributed to the final model. The proportional meta-analysis showed a pooled proportion positive for chlamydia of 7.7% (95% CI 5.2% to 10.6%). All the studies were reported on Conclusion The reported prevalence of chlamydia infection in pharmacy setting is similar to estimates from general practice thus giving wider choice of care to young people. This new approach is acceptable to both young people and pharmacists. Encouraging men and ethnic minorities to access community pharmacy based chlamydia services remains a challenge.

Background HIV transmission in India is concentrated among high-risk groups. Female sex workers (FSWs) and Clients of FSWs are the most vulnerable groups at risk for HIV. This paper presents the prevalence of sexually transmitted infections (STIs) and HIV among FSWs and their clients in the states of Andhra Pradesh (AP), Tamil Nadu (TN) and Maharashtra (MH) from repeated, cross-sectional, bio-behavioural surveys. Methods Data from two rounds of Integrated Behavioural and Biological Assessments conducted in 2005 (R1) and 2009 (R2) among 15 632 FSWs (R1-7828, R2-7804) and 9624 clients of FSWs (R1-4821, R2-4803) were analysed to observe the changes in STI and HIV prevalence among each group. Respondents9 behaviour was assessed and blood and urine samples were collected to test for STIs [ Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), syphilis and HIV]. Analysis at both the aggregate and state level was done. Adjusted ORs were obtained by including all socio-demographic variables associated with rounds of survey in multivariate models. Results At the aggregate level, among FSWs, prevalence of syphilis declined from 10.8% in R1 to 5.0% in R2 (AOR 0.39, p=0.001) and no significant change was observed in prevalence of HIV, NG or CT. Among FSW clients, STI prevalence was low in R1 (syphilis 4.7%, NG 0.4% and CT 2.4%) and no significant change was observed in R2. The state-wide trend shows that for FSWs in AP, a significant decline occurred in prevalence of both HIV (AOR 0.68, p Conclusion The prevalence of syphilis declined among both FSWs and their clients in all three states whereas no change was seen in other bacterial STI prevalence (NG or CT). Among FSW clients in MH and TN, STI prevalence remained unaltered. Tailored and sustained programmatic efforts are needed to address the disparity in prevalence of STIs and HIV in the three states.

An outbreak of lymphogranuloma venereum (LGV) infection has been recognised in the UK since 2004, predominantly affecting HIV-positive men who have sex with men (MSM). Patients typically present with proctitis symptoms. The prevalence of rectal LGV in MSM attending sexually transmitted infection clinics in London is estimated at 1%. Health Protection Agency surveillance has shown a decrease in anorectal manifestations despite little demographic change. Two cases of HIV-infected patients presenting with isolated perianal ulcer disease are reported here. Both cases were confirmed to have rectal Chlamydia trachomatis-specific DNA of an LGV associated serovar. As presentations of LGV diversify, further education and surveillance are needed in order to reduce transmission and prevent long-term complications. A strong argument already exists for the incorporation of chlamydia nucleic acid amplification tests in the management of MSM with proctitis; this paper provides evidence that this should be extended to MSM with perianal ulcer disease.

The focus on chlamydia in this issue of STI is timely. A debate on the second day of the 17th International Society for STD Research and 10th International Union against STI meeting in Seattle on 30 July will address the topic “Epidemiology of chlamydial infection: are we losing ground?” The first “special issue” about sexually transmitted Chlamydia trachomatis in this journal, then called the British Journal of Venereal Diseases , was published in December 1972 when seven articles examined diagnostic and clinical aspects of a new sexually transmitted infection.1 Chlamydia is now the most commonly reported of all infections in countries like the USA and Sweden. The papers collected here address new aspects of C trachomatis but also articulate the growing uncertainties about our efforts to control this pathogen. Screening asymptomatic individuals seems to many people to be the obvious solution to prevent the transmission and adverse consequences of chlamydia,2 including preterm delivery and premature rupture of membranes in pregnant women. (see p 314)3 It is also a very expensive solution. (see p 267)4 The economic modelling and evaluation study by Adams et al shows that it is going to be difficult for the opportunistic strategy being implemented by the National Chlamydia Screening Programme in England to be cost effective. Proactive screening, using population registers to identify and invite people to be screened regularly, is usually assumed to be more expensive to run than opportunistic screening. Robinson et al 5 estimated the health service and patient costs of a postal chlamydia screening approach in England. (see p 276) The cost per invitation was actually similar to that of an organised opportunistic screening programme.6 We are learning the hard way that delivering chlamydia screening effectively and efficiently is easier than it sounds.7 If …

Useful adjuncts to a more general population chlamydia screening programme Where should chlamydia screening be done? Who should be screened? How do we engage young men and vulnerable groups? How do we increase the uptake? Can the internet help? As a timely response to a recent call for innovative ways to encourage chlamydia screening in young people,1 we publish two papers (pp 142 and 148) and a commentary (p 152) tackling some of these issues. Gotz et al ’s pilot study in Rotterdam examined ways of encouraging chlamydia screening among African Caribbeans from Surinam and the Antilles (see p 148). In a previous population based study this group was at higher risk of infection than white Dutch people,2 but less likely to respond to a postal invitation to provide home collected specimens for chlamydia testing.3 In this study, urine collection kits were offered by street outreach workers, or public health nurses providing sex education in vocational training schools. Participants could provide a specimen on site, or take a kit home with them. In the school and group settings uptake among the minority ethnic group was higher than in the postal intervention.3 The positivity rate in female vocational training school students was extremely high (27.9%, 95% CI 16.7% to 42.6%). In contrast with targeting specific groups and settings, Novak and Karlsson set up an internet website to promote chlamydia testing to the whole adult population in one Swedish county (see p 142). Visitors to the site could request …

Background Tver region belongs to the Central part of Russia, its territory is 84,200 km 2 with a population of 1,342,200 inhabitants, including the city of Tver populated by 406,918 inhabitants. The aim of this paper is for the first time to internationally present the epidemiological trends of STIs in the region. Methods Site visits and yearly epidemiological reports of the Center. Results The peripheral laboratories are poorly equipped and therefore the diagnosis of STIs is mainly concentrated to the Center of the Specialized Medical Aid in Tver. However, the long distances for specimen transportation and lack of appropriate transport system are large obstacles for providing effective diagnosis of STIs. In 2009, vaccination against human papilloma virus (HPV) was introduced into the prevention programme against cervical cancer in Tver. The epidemiological trends of the main STIs in the Tver region are changing. A decrease in the incidence (cases per 100,000 inhabitants) of almost all STIs has been observed, namely during the years 2008 and 2012 the incidence of syphilis was 62.1 and 21.0, gonorrhoea - 42.5 and 19.2, genital chlamydial infection - 58.7 and 34.4 cases, T vaginalis - 120.5 and 73.6, genital herpes - 8.1 and 6.5, and anogenital warts 21.1 and 16.6, respectively. Since introduction in 2009, 373 girls, aged 12–13 years, have been vaccinated for HPV. Conclusion . In Tver, Russia, the difficulties to reach the population in most need for testing is of major concern. The reported epidemiologic data is also suboptimal due to many reasons such as lack of appropriate diagnostic methods, frequent use of self-treatment (antibiotics available over the counter), and private laboratories and outpatient clinics do commonly not report STI cases to the authorities. Accordingly, it is imperative to optimise the laboratory diagnosis and epidemiological surveillance of STIs, and introduce evidence-based STI guidelines.

Background The decision to implement a Chlamydia screening programme is based on a detailed assessment of its projected impact and cost-effectiveness. In the absence of evidence from randomised controlled trials, transmission dynamic models are crucial to this process. However these models are highly sensitive to the representation of the infection. We review the evidence used to inform the model parameters highlighting their strengths and limitations. Methods Published economic analyses of chlamydia screening interventions were identified following a systematic search of the literature. Only transmission dynamic models were included as they represent the gold standard. Parameters describing chlamydia infection were extracted and the variability across the studies assessed. The data used to inform each parameter was sourced and critically evaluated. Results Eleven studies were included in this review, all evaluating chlamydia screening programme designs in developed countries. Many key natural history parameters are based on sparse historical data and there is wide variation in the values used across the models. For example, The per act transmission probability ranging from 3.75% to 15.3%. The modelled duration of asymptomatic infection was between 180–370 days in women and 40–200 days in men. Only one paper includes a period of protective immunity following infection. Only 2 studies consider the role of reinfection in the development of complications However, there is a general consensus in the proportion of people that are asymptomatic; between 70–75% of women and 25–50% of men. Conclusion We highlight the variability in descriptions of the natural history and emphasise the importance of using contemporary data to inform modelling studies. A clear consensus on the appropriate representation of the natural history is needed, with estimates continuously updated using new evidence.

Introduction In many settings, control of sexually transmissible infections (STIs) is compromised by lack of laboratory infrastructure, physical distance from laboratories and loss to follow up of patients. Point-of-care (POC) tests have the potential to provide timely diagnosis, treatment and partner notification, and in turn reduce infection rates. In April 2013, we will implement the first cluster randomised trial of chlamydia and gonorrhoea POC testing in remote Aboriginal communities where STIs are endemic. Methods The study, called TTANGO (test, treat and go), will measure the effectiveness, cost-effectiveness and cultural and operational acceptability of POC testing for chlamydia and gonorrhoea infections. The study design is a crossover, cluster, randomised controlled trial involving 12 health services in remote Aboriginal communities in Australia. The primary outcome is the percentage of people with persistent chlamydia and gonorrhoea positive tests. The trial runs for 2 years and is a partnership between research, government and community organisations. Results TTANGO is reaching the conclusion of the preparation phase and has achieved significant steps, including the engagement of remote health services and communities, a comprehensive laboratory and field evaluation to select the ideal assay, development of the first formal training package for chlamydia and gonorrhoea POC testing, and a quality assurance programme. The GeneXpert® CT/NG molecular POC assay was selected for the trial as it showed very high sensitivity and specificity compared to other assays, was easy to use and results were available in approximately 90 minutes. This paper will discuss progress in preparing and implementing TTANGO, the methodology and evaluation. Conclusion The results of this RCT will provide crucial information to guide sexual health clinical practise in remote Aboriginal communities and other settings internationally. Mathematical modelling and health economic analyses will be used to make the case for large scale implementation of this technology.

There is hope that trachoma will be the first major bacterial disease eliminated by a worldwide effort A few minutes spent searching Medline reveals some interesting trends: while the total number of scientific publications has exploded over the past 35 years, the number of papers incorporating the keyword “trachoma” has actually decreased (Fig 1A). The number of reviews of trachoma, however, has increased (Fig 1B). Is this a sign that the study of trachoma has matured—that effective treatments are well known and that the only challenge left is to implement them? Many recent editorials have indeed suggested that a wide variety of treatments are effective.1–6 In fact, studies suggest that trachoma is disappearing even in the absence of a programme specifically targeting the disease.7–10 Is the war against trachoma, or at least the scientific part, finally over? The past decade has witnessed numerous advances in chlamydia research: the chlamydial genome has been sequenced,11 diagnosis with sensitive nucleic acid amplification tests has become routine,12–14 and randomised clinical trials have purported to demonstrate the efficacy of behavioural,15 pharmacological,16 and even entymological17 control measures in reducing the prevalence of trachoma. A course of three doses of oral azithromycin administered to all members of a community was shown to be as effective as a 6 week course of topical tetracycline.18 This is important because compliance with oral azithromycin is clearly far superior. Another trial suggested that an …

Background Concurrent sexual partnerships create higher network connectivity and increase spread of STI through their sexual networks. Recently in our prospective cohort study SWAP (Swingers World Attitude and Practice) swingers were identified as a high transmission population for STI. Swingers, heterosexual couples together having sex with others, by definition are involved in concurrent sexual relationships. Objective of the present paper is to examine indicators for the level of concurrency in sexual relations among swingers predicting high potential of STI transmission. Methods Participants of the SWAP cohort were followed using (network) questionnaires and STI consultations. Urogenital, oropharyngeal and anorectal samples were tested for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) by NAAT. STI is defined as positive CT and/or NG diagnosis. We used epidemiological (SPSS) and social network methods for the analysis of the data. Different indicators for level of concurrency were measured: frequency of swinging; types and number of sex partners; and involvement in group sex (sexual intercourse at the same moment in time with multiple partners), all during the past 6 months. Results Of the 106 respondents, median age 43 years, 13.2% were diagnosed positive for STI. Of the swingers 96% were in a steady relationship, 5% formed a swinging couple with a friend not being their steady partner, 9% also had casual sex partners outside swinging with median 4 sex partners. Median frequency of swinging was 10 times, with median 7 swing sex partners in 6 months. Median number of swing sex partners during an average swinging date was 2; 59% practiced group sex with median 3 sex partners. Median total number of sex partners was 9 in 6 months. Abstract P1-S5.38 table 1 shows frequency of swinging, participating in group sex and total number of sex partners were significantly correlated with having STI. Conclusions Swingers have concurrent sexual relations with a range of different types and numbers of sex partners and therefore transmission of STI through connected networks is highly plausible. Some of the presented indicators of level of concurrency are associated with STI infection. Further analysis of the concurrency measures, STI related risk behaviours, and the sexual networks of swingers, is necessary to examine how concurrent sexual partnerships form these networks and influence STI transmission through them.

Background Studies among high-risk groups (HRGs) have shown that the presence of STIs is associated with certain demographic and behavioural characteristics as well as exposure to HIV/STI prevention interventions. The objective of this study was to understand the correlates of STIs in female sex workers (FSWs) in India in order to improve STI programming for HRGs. Methods During 2008–2009, 417 female sex workers were recruited from three STI clinics in two cities of India as part of an operations research to evaluate the effectiveness of STI prevention service package for sex workers under Avahan, the India AIDS Initiative of the Bill & Melinda Gates Foundation. Behavioural and clinical information along with biological samples were collected. Bivariate analysis of demographic and behavioural characteristics associated with the prevalence of common bacterial STIs- Neisseria gonorrhoeae , Chlamydia trachomatis , Treponema pallidum and Trichomonas vaginalis from the baseline data is presented in this paper. Results At baseline 49.2% of the participants had a laboratory confirmed diagnosis for at least one of the four bacterial STIs. The significant factors associated with STI prevalence among FSWs were: inability to read or write (OR=2.2, p=0.002); not staying with a sexual partner (OR=1.5, p=0.036); typology of sex work: home-/hotel-based (OR=2.5, p=0.038) vs brothel-based and street-based (OR=3.1, p=0.004) vs brothel-based; regular or occasional consumption of alcohol (OR=1.9, p=0.002); poor knowledge of STI symptoms (OR=1.6, p=0.017); low self-risk perception for acquiring STIs (OR=1.6, p=0.031); less than 2 years in sex work (OR=1.8, p=0.008); no prior exposure to HIV/STI interventions (OR=2.0, p=0.001); and no STI check-ups in the past 6 months (OR=1.5, p=0.029) see [Abstract P2-S2.07 Table 1][1]. View this table: Abstract P2-S2.07 Table 1 Factors associated with sexually transmitted infections among female sex workers in India Conclusions HIV/STI prevention programs for FSWs in India need to prioritise services for HRGs who have characteristics associated with STI prevalence. Additionally, awareness activities should promote the importance of regular STI check-ups, recognition and early treatment for STI symptoms. [1]: #T1

Background The Australian Government has funded the Australian Chlamydia Control Effectiveness Pilot (ACCEPt), a randomised controlled trial of a chlamydia testing intervention to assess the feasibility, acceptability and cost-effectiveness of chlamydia testing in general practice clinics. There are well documented barriers to increased chlamydia testing in general practice including time, cost, and clinicians9 knowledge and awareness of chlamydia. If an intervention is to successfully increase chlamydia testing, it must minimise these barriers and take the uniqueness of each general practice into consideration. This paper describes the chlamydia testing intervention being implemented in ACCEPt. Methods Clinics in the intervention group are being provided with a multifaceted evidence-based intervention designed to increase annual chlamydia testing for sexually active 16–29 year olds. The intervention includes: a computer alert prompting GPs to test; incentive payments for GPs and practice nurses to conduct testing; an annual recall system involving SMS, phone or mail reminders; a comprehensive education pack; and regular feedback on testing performance. The intervention will be in place for up to 4 years, and will be tailored to the resources and needs of each clinic. Prior to implementation, clinic staff are engaged and given the opportunity to identify methods for improving chlamydia testing within their clinic, using an evidence-based practice assessment tool. Results To date, 69 clinics in 24 areas have been recruited across three Australian states. Four of these areas (9 clinics) have been randomised: two areas (7 clinics) are in the intervention group, and two areas (2 clinics) in the control group. The intervention has been customised to each clinic with two thirds of clinics receiving the computer alert, 4 clinics using SMS reminders for recall, others using a mail recall and some using practice nurses to initiate chlamydia testing. Where possible, doctors and practice nurses have been given one on one education and training about chlamydia and pelvic inflammatory disease. Conclusions Given that each Australian general practice is unique, it is vital that the intervention is tailored to individual clinic needs to achieve sustainable system changes. This enables maximum staff engagement to ensure the effective uptake of increased chlamydia screening in the Australian general practice setting.

In September 1991 the 7th IUVDT Regional Conference on Sexually Transmitted Diseases (STDs) convened in Kuala Lumpur Malaysia to exchange information on the importance of controlling STDs and HIV-AIDS in Asia. Speakers from Thailand Malaysia and Japan provided the latest HIV-AIDS epidemiological data. In Thailand heterosexual transmission of HIV is catching up with iv drug use. Most infected women are 15-24 years old. In Malaysia drug use iv drug use trails heterosexual transmission of HIV. In Japan hemophiliacs comprise 85% of HIV-positive people. Current problems do not compare to the sizable task Asian countries face in affecting the progression of the HIV-AIDS epidemic. All countries need to implement control measures quickly and at the same time. They should not pretend traditional values and beliefs would shield their people from the epidemic. Asian countries should especially stop promoting themselves as places of sexual adventure. Control programs should also target STDs. Australian presenters discussed the results of the Sydney Sexual Lifestyle Study and a study on the effect of zidovudine therapy on the prognosis of AIDS. Another presentation focused on the possibility of a vaccine for chlamydia infection. Several papers centered on the treatment of chancroid and gonococcal and nongonococcal urethritis and evaluation of a detection test for chlamydia infection. 1 participant reviewed the role of human papilloma virus in cervical carcinogenesis. Another participant demonstrated a link between bacterial vaginosis and adnexal tenderness and pelvic infection. The conference concluded with a presenter challenging everyone to meet the HIV-AIDS challenge. Reasons why current control measures do not work include inadequate facilities to manage STDs tendency not to consider HIV another STD failure to promote and lack of condoms and not educating school children about HIV-AIDS.

Editor—The relation of Chlamydia pneumoniae antibodies to ischaemic heart disease reported by Strachan et al, and the commentary on the paper, deserve comment.1 An association is reported between IgA antibody at the start of the study and prevalent ischaemic heart disease or subsequent death due to ischaemic heart disease. Presumably, serum samples with an IgG antibody titre of