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Competing Interests: Declaration of competing interest The author declares no conflicts of interest.

Sexually transmitted diseases (STDs) are a major public health problem now compounded by the advent of AIDS and HIV infection. The size of the problem represented by STDs and HIV is unknown however it is estimated that there are 333 million new cases of STD per annum and currently 15-20 million people infected worldwide with HIV. Control programmes for STDs must prevent the acquisition of STDs, their complications and sequelae and interrupt and reduce transmission. They can also reduce the incidence of HIV infection. Such programmes must place emphasis on health education, condom usage, altering health seeking behaviour and providing case management. The syndromic approach currently offers the most realistic, and cost effective, way in which to treat patients.

Sexually transmitted diseases (STDs) continue to increase in number throughout the world, as do the number of agents that are spread by the sexual route; the most recent new agent is the human immunodeficiency virus. Most countries do not have adequate control programs for STDs or training programs for physicians and nurses designated to look after patients. The diseases are associated with considerable morbidity and recently, with the advent of the acquired immunodeficiency syndrome, with considerable mortality.

The effect on the work load in one of two clinics featured in a television programme devoted to the sexually transmitted diseases was monitored. The patients' source of referral was recorded before and after the programme and the number of telephone inquiries noted during the same periods. For the two weeks after the programme 18% of the male patients and 13% of the female patients attending the clinic came as a result of watching it. A sexually transmitted disease was diagnosed in 30% and 22% of those men and women respectively. This proportion of positive diagnoses was lower than for other sources of referral. The mean number of telephone inquiries rose by 56% after the programme.

A study was conducted to identify and estimate the proportion of patients suffering from gonorrhoea, trichomoniasis, and candidosis, both with and without symptoms, seeking care or failing to seek care at all. Samples women in a defined population were studied in antenatal, gynaecology, family planning, and sexually transmitted diseases clinics and in general practice. The incidence rates varied according to the conditions and to whether cases not proved microbiologically were included or excluded. The incidence rate may be less important than the prevalence rate since the former takes into account patients who have sought care whereas the latter is largely contributed by asymptomatic women who do not consult. The highest prevalence rates, in different agencies, were found for candidosis followed by trichomoniasis, with very low or zero rates for gonorrhoea. In view of these results general practitioners could treat women with genital symptoms empirically so long as accurate sexual histories are taken and follow-up were guaranteed. There is no place for wide-scale screening for gonorrhoea, but limited screening for trichomoniasis in antenatal, gynaecology, and hospital family planning clinics should be encouraged.

Twenty-six medical schools in the United Kingdom have recently taken part in a survey on the teaching of genitourinary medicine (venereology) to undergraduates. Four of the schools were unable to run their own formal lecture courses and a further three could not offer clinical attachments. The mean number of lectures given per centre was six, clinic attendances 10 hours, and total teaching time (lectures and clinical attachment combined) 15 hours. This represents a reduction in teaching hours over the last 15 years and contrasts with the ever-increasing clinical problems associated with the sexually transmitted diseases.

The provision of the sexually transmitted disease clinic service in the regional health authorities of England and Wales has been compared by relating the opening hours of clinics to the size of the population served. Relatively low levels of service were provided in the West Midlands and South-west Thames regions and high levels in the North-east and North-west Thames regions. When the service in the Greater London area health authorities was examined in relation to both resident and day-time populations, provision was relatively high in both instances, particularly in certain central London areas. Valid conclusions, however, about the equality of the service in different areas can only be drawn if the needs of the population for that service are known.

The current methods of treating and reporting non-specific genital infection (NSGI) are described. The most commonly used drug was tetracycline in one or other form. Epidemiological treatment was widely used, particularly for female sexual contacts. There was considerable variation in the reporting criteria for the quarterly returns. The establishment of acceptable and uniform criteria for notification of NSGI is discussed.

A study was conducted to collect information from consultants about the facilities and diagnostic criteria used in clinics for sexually transmitted diseases in England and Wales. Most of the information was obtained by personal interview with a response rate of 92%. Half the clinics were open for 10 hours or less a week, the mean length of time for all clinics was 14 1/2 hours a week. Eighty per cent of clinics had a full or part-time contact-tracing service. All the clinics had microscopical and serological services and almost all (99%) had cultural facilities. The policy concerning the most efficient use of these facilities is discussed.

A study was carried out to quantify and describe patients seen in sexually transmitted diseases clinics in England and Wales during 1978. Nine per cent of male patients were homosexual and 58% of female patients were under 25 years compared with only 42% of heterosexual men. Homosexual men had a higher mean number of cases per patient during the year than heterosexual men or women, largely because thay were more likely to have multiple episodes of disease. Female patients also had a higher mean number of cases than heterosexual men, because they often had several concurrent infections. There were 100,000 fewer patients than cases (322,000 compared with 432,000); 41% were seen in clinics in London. These findings show that current statistics for STDs are inadequate. Some quantification and categorisation of patients treated would be useful in analysing the trends in the incidences of the STDs.

Data previously collected on the facilities and diagnostic criteria used in clinics for sexually transmitted diseases in England and Wales were reanalysed to established how different consultant policies affected the management of individual cases. Several discrepancies were found between conclusions based on percentages of clinics and those based on numbers of cases. Full-time facilities for contact tracing were available to more cases than previously suggested and rectal sampling in women was more widespread. Laboratory facilities were limited and cultural facilities lacking in small clinics, which thus affected only a small number of cases. Previous indications that diagnostic criteria were fairly standardised in the diagnosis of non-specific urethritis were found to be invalid. Variation in the management of individual cases was found to lead to inconsistencies in the notification of STDs to the Department of Health and Social Security.

A study of diagnostic patterns in patients attending sexually transmitted disease clinics in England and Wales during 1978 showed that homosexuals contributed 10% of all male cases but 15% of gonococcal infections. In heterosexual and homosexual men only 6% of disease episodes included more than one positive diagnosis compared with 16% in women. One or more diseases occurred concurrently in over 30% of cases of gonorrhoea, trichomoniasis, candidosis, genital herpes, and genital warts in women. Men with multiple episodes of disease contributed a disproportionate number of gonococcal infections but were less likely to have candidosis or genital herpes than patients with only one disease episode. Thus, counting cases treated appears to be an inadequate way of measuring the problems caused by STDS. To enable more rapid identification of the diseases which are the most difficult to control, STD statistics should include the sexual orientation of male patients and differentiate between genuine "new" attenders at clinics and those previously seen.

Over the past 10 years there has been a pronounced increase in the number of cases of genital herpes seen in sexually transmitted disease (STD) clinics in the United Kingdom. The reporting system, however, does not differentiate between primary and recurrent infections, and consequently any increase in the number of patients reattending clinics with recurrent genital herpes would falsely inflate the statistics. A study of cases of herpes seen in the department of genitourinary medicine of this hospital in the two years 1972 and 1982 is presented. It showed that the proportion of patients attending with recurrent herpes had increased from 18% in 1972 to 31% in 1982. As a result of this, the 68% increase between 1972 and 1982 in the total number of cases of herpes seen in the clinic overestimates the real increase in the size of the problem, which is closer to 40%, based upon cases of primary herpes only. Modifications to the national recording system are necessary to overcome the problems highlighted by this study. These modifications could include classifying each case of genital herpes as primary, recurrent, or recurrent but not previously recorded, which would provide a more accurate picture of the size of the problem of genital herpes in the population.

A substantial number of problems are associated with the present notification system on sexually transmitted diseases. Since a comprehensive and uniform system is vitally important to all clinicians in indicating changes in disease incidence and patterns, some modifications are proposed to make the system of more direct clinical relevance.

The current methods of diagnosis for non-specific genital infection (NSGI) in clinics in England and Wales are described. In most clinics (92%) microscopical findings were used by consultants to establish the diagnosis of non-specific urethritis (NSU) in male patients. However, the microscopical criteria that they used in reaching a diagnosis varied between clinics. The most commonly applied criterion was that of less than five leucocytes per high power field. NSGI in female patients and non-specific proctitis in passive homosexuals were recognised as distincy in 60% of clinics and the latter in 57%. Among those who recognised these conditions the diagnostic criteria varied. The establishment of acceptable and uniform criteria for diagnosis are discussed.

The author reflects on the reliability of the statistics on sexually transmitted disease in Great Britain. In the author's view, even though the notification system and statistics in the country are better than in most countries, there are several drawbacks and omissions. For example, the notified figures relate to the number of cases, not patients, which means that a patient can reappear several times in the published statistics for a year, and can do so for several different reasons.