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Background: Antimicrobial resistance in Neisseria gonorrhoeae is a global public health concern. Tetracycline resistance (TetR) increased from 39.4% to 75.2% between 2016 and 2021 in N. gonorrhoeae isolates collected through national surveillance in England, despite the absence of use of tetracyclines for the treatment of gonorrhoea., Objectives: We investigated whether there was correlation between bacterial sexually transmitted infection (STI) tests performed and treatment with antimicrobials, with increased TetR in N. gonorrhoeae., Methods: We examined correlations between bacterial STI tests, antimicrobial treatment and TetR in N. gonorrhoeae, using national surveillance data from three large sexual health services (SHS) in London during 2016-20. Doxycycline prescribing data and antibiograms of a non-STI pathogen from distinct patient groups (sexual health, obstetric and paediatric), at a large London hospital, were analysed to identify if doxycycline use in SHS was associated with resistance in a non-STI organism., Results: A substantial increase in TetR was observed, particularly in isolates from gay, bisexual and other MSM (GBMSM). Strong positive correlations were observed exclusively in GBMSM between N. gonorrhoeae TetR and both bacterial STI tests (r = 0.97, P = 0.01) and antimicrobial treatment (r = 0.87, P = 0.05). Doxycycline prescribing increased dramatically during the study period in SHS. Prevalence of TetR in Staphylococcus aureus was higher in isolates sourced from SHS attendees than those from other settings., Conclusions: Frequent screening of GBMSM at higher risk of STIs, such as those on pre-exposure prophylaxis (PrEP) leading to/and increased use of doxycycline for the treatment of diagnosed infections, may account for the increase in TetR in N. gonorrhoeae., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Competing Interests: Competing interests: None declared.

Objectives: Azithromycin treatment of Chlamydia trachomatis (CT) may not be adequate to treat concomitant Mycoplasma genitalium (MG) infection, and particularly if MG has macrolide resistance-associated mutations (MG-MRAMs). We estimated prevalence of coinfections of CT with MG carrying MRAM, and risk factors for MG-MRAM among a sexual health clinic population., Study Design and Setting: Among symptomatic and STI-contact clinic attendees in London, prevalence of CT-MG coinfection and MG-MRAM were estimated using nucleic acid amplification testing and Sanger sequencing, respectively, and their associated risk factors analysed using logistic regression., Results: MG prevalence was 7.5% (23/307), 17.3% (30/173), and 11.4% (8/70) in females, men who have sex with women (MSW) and men who have sex with men (MSM), respectively; MG coinfection in CT-infected participants represented 28.0% (7/25), 13.5% (5/37), 0.0% (0/0), respectively. Presence of MG-MRAM was 39.1% (9/23) in female swabs, 70.0% (21/30) in MSW urine and 83.3% (5/6) in MSM rectal swabs. In multivariate analyses, coinfection with another STI was strongly associated with MG-MRAM (OR: 7.19; 95% CI: 2.4 to 21.5)., Conclusion: A significant proportion of participants in our study of symptomatic patients and STI contacts were infected with macrolide-resistant MG, suggesting that testing for MG and MRAM, for MG positives, might be clinically useful. The findings also suggest services explore potential benefits of testing CT positive samples for MG in these patient groups. Where MG testing is not available, potential high rates of MG coinfection should be borne in mind when considering azithromycin in the treatment of CT among STI contacts and symptomatic patients., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Low uptake of sexually transmitted infection testing by sexually active young people is a worldwide public health problem. Screening in non-medical settings has been suggested as a method to improve uptake. The "Test n Treat" feasibility trial offered free, on-site rapid chlamydia/gonorrhoea tests with same day treatment for chlamydia (and gonorrhoea treatment at a local clinic,) to sexually active students (median age 17 years) at six technical colleges in London. Despite high rates of chlamydia (6% prevalence), uptake of testing was low (< 15%). In a qualitative study we explored the acceptability, including barriers and facilitators to uptake, of on-site chlamydia screening., Methods: In 2016-17 we conducted a qualitative study in the interpretative tradition using face to face or telephone semi-structured interviews with students (n = 26), teaching staff (n = 3) and field researchers (n = 4). Interviews were digitally recorded, transcribed and thematically analysed., Results: From the student perspective, feelings of embarrassment and the potential for stigma were deterrents to sexually transmitted infection testing. While the non-medical setting was viewed as mitigating against stigma, for some students volunteering to be screened exposed them to detrimental judgements by their peers. A small financial incentive to be screened was regarded as legitimising volunteering in a non-discrediting way. Staff and researchers confirmed these views. The very low level of knowledge about sexually transmitted infections influenced students to not view themselves as candidates for testing. There were also suggestions that some teenagers considered themselves invulnerable to sexually transmitted infections despite engaging in risky sexual behaviours. Students and researchers reported the strong influence peers had on uptake, or not, of sexually transmitted infection testing., Conclusions: This study offers new insights into the acceptability of college-based sexually transmitted infection screening to young, multi-ethnic students. Future studies in similar high risk, hard to reach groups should consider linking testing with education about sexually transmitted infections, offering non stigmatising incentives and engaging peer influencers.

Background: Community-based screening may be one solution to increase testing and treatment of sexually transmitted infections in sexually active teenagers, but there are few data on the practicalities and cost of running such a service. We estimate the cost of running a 'Test n Treat' service providing rapid chlamydia (CT) and gonorrhoea (NG) testing and same day on-site CT treatment in technical colleges., Methods: Process data from a 2016/17 cluster randomised feasibility trial were used to estimate total costs and service uptake. Pathway mapping was used to model different uptake scenarios. Participants, from six London colleges, provided self-taken genitourinary samples in the nearest toilet. Included in the study were 509 sexually active students (mean 85/college): median age 17.9 years, 49% male, 50% black ethnicity, with a baseline CT and NG prevalence of 6 and 0.5%, respectively. All participants received information about CT and NG infections at recruitment. When the Test n Treat team visited, participants were texted/emailed invitations to attend for confidential testing. Three colleges were randomly allocated the intervention, to host (non-incentivised) Test n Treat one and four months after baseline. All six colleges hosted follow-up Test n Treat seven months after baseline when students received a £10 incentive (to participate)., Results: The mean non-incentivised daily uptake per college was 5 students (range 1 to 17), which cost £237 (range £1082 to £88) per student screened, and £4657 (range £21,281 to £1723) per CT infection detected, or £13,970 (range £63,842 to £5169) per NG infection detected. The mean incentivised daily uptake was 19 students which cost £91 per student screened, and £1408/CT infection or £7042/NG infection detected. If daily capacity for screening were achieved (49 students/day), costs including incentives would be £47 per person screened and £925/CT infection or £2774/NG infection detected., Conclusions: Delivering non-incentivised Test n Treat in technical colleges is more expensive per person screened than CT and NG screening in clinics. Targeting areas with high infection rates, combined with high, incentivised uptake could make costs comparable., Trial Registration: ISRCTN58038795, Assigned August 2016, registered prospectively.

Objective: We aimed to characterise gonorrhoea transmission patterns in a diverse urban population by linking genomic, epidemiological and antimicrobial susceptibility data., Methods: Neisseria gonorrhoeae isolates from patients attending sexual health clinics at Barts Health NHS Trust, London, UK, during an 11-month period underwent whole-genome sequencing and antimicrobial susceptibility testing. We combined laboratory and patient data to investigate the transmission network structure., Results: One hundred and fifty-eight isolates from 158 patients were available with associated descriptive data. One hundred and twenty-nine (82%) patients identified as male and 25 (16%) as female; four (3%) records lacked gender information. Self-described ethnicities were: 51 (32%) English/Welsh/Scottish; 33 (21%) white, other; 23 (15%) black British/black African/black, other; 12 (8%) Caribbean; 9 (6%) South Asian; 6 (4%) mixed ethnicity; and 10 (6%) other; data were missing for 14 (9%). Self-reported sexual orientations were 82 (52%) men who have sex with men (MSM); 49 (31%) heterosexual; 2 (1%) bisexual; data were missing for 25 individuals. Twenty-two (14%) patients were HIV positive. Whole-genome sequence data were generated for 151 isolates, which linked 75 (50%) patients to at least one other case. Using sequencing data, we found no evidence of transmission networks related to specific ethnic groups (p=0.64) or of HIV serosorting (p=0.35). Of 82 MSM/bisexual patients with sequencing data, 45 (55%) belonged to clusters of ≥2 cases, compared with 16/44 (36%) heterosexuals with sequencing data (p=0.06)., Conclusion: We demonstrate links between 50% of patients in transmission networks using a relatively small sample in a large cosmopolitan city. We found no evidence of HIV serosorting. Our results do not support assortative selectivity as an explanation for differences in gonorrhoea incidence between ethnic groups., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The BASHH guidelines recommend molecular tests to aid diagnosis of Trichomonas vaginalis (TV) infection; however many clinics continue to use relatively insensitive techniques (pH, wet-prep microscopy (WPM) and culture). Our objectives were to establish a laboratory pathway for TV testing with the Becton-Dickinson Qx (BDQx) molecular assay, to determine TV prevalence and to identify variables associated with TV detection., Methods: A prospective study of 901 women attending two urban sexual health services for STI testing was conducted. Women were offered TV BDQx testing in addition to standard of care. Data collected were demographics, symptoms, results of near-patient tests and BDQx results for TV, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) . Women with any positive TV result were treated and followed up for test of cure (TOC)., Results: 901 women had a TV BDQx test. 472 (53%) were white, 143 (16%) black and 499 (55%) were symptomatic. Infections detected by BDQx were: 11 TV (1.2%), three GC (0.3%) and 44 CT (4.9%). Of the 11 BDQx-detected TV infections, 8 (73%) were in patients of black ethnicity. Of these, four of seven cases (57%) were WPM-positive. All patients received treatment and nine of nine (100%) were BDQx-negative at TOC. In univariate analysis, only black ethnicity was associated with likelihood of a positive TV BDQx result (relative risk (RR) 10.2 (95% CI 2.15 to 48.4))., Conclusions: The use of the BDQ enhanced detection of TV in asymptomatic and symptomatic populations. Cost-effective implementation of the test will rely on further work to reliably detect demographic and clinical variables that predict positivity., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives: Online services for self-sampling at home could improve access to STI testing; however, little is known about those using this new modality of care. This study describes the characteristics of users of online services and compares them with users of clinic services., Methods: We conducted a cross-sectional analysis of routinely collected data on STI testing activity from online and clinic sexual health services in Lambeth and Southwark between 1January 2016 and 31March 2016. Activity was included for chlamydia, gonorrhoea, HIV and syphilis testing for residents of the boroughs aged 16 years and older. Logistic regression models were used to explore potential associations between type of service use with age group, gender, ethnic group, sexual orientation, positivity and Index of Multiple Deprivation (IMD) quintiles. We used the same methods to explore potential associations between return of complete samples for testing with age group, gender, ethnic group, sexual orientation and IMD quintiles among online users., Results: 6456 STI tests were carried out by residents in the boroughs. Of these, 3582 (55.5%) were performed using clinic services and 2874 (44.5%) using the online service. In multivariate analysis, online users were more likely than clinic users to be aged between 20 and 30 years, female, white British, homosexual or bisexual, test negative for chlamydia or gonorrhoea and live in less deprived areas. Of the individuals that ordered a kit from the online service, 72.5% returned sufficient samples. In multivariate analysis, returners were more likely than non-returners to be aged >20 years and white British., Conclusion: Nearly half (44.5%) of all basic STI testing was done online, although the characteristics of users of clinic and online services differed and positivity rates for those using the online service for testing were lower. Clinics remain an important point of access for some groups., Competing Interests: Competing interests: PB is a director of SH:24., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Unlabelled: Gonorrhea is a sexually transmitted disease causing growing concern, with a substantial increase in reported incidence over the past few years in the United Kingdom and rising levels of resistance to a wide range of antibiotics. Understanding its epidemiology is therefore of major biomedical importance, not only on a population scale but also at the level of direct transmission. However, the molecular typing techniques traditionally used for gonorrhea infections do not provide sufficient resolution to investigate such fine-scale patterns. Here we sequenced the genomes of 237 isolates from two local collections of isolates from Sheffield and London, each of which was resolved into a single type using traditional methods. The two data sets were selected to have different epidemiological properties: the Sheffield data were collected over 6 years from a predominantly heterosexual population, whereas the London data were gathered within half a year and strongly associated with men who have sex with men. Based on contact tracing information between individuals in Sheffield, we found that transmission is associated with a median time to most recent common ancestor of 3.4 months, with an upper bound of 8 months, which we used as a criterion to identify likely transmission links in both data sets. In London, we found that transmission happened predominantly between individuals of similar age, sexual orientation, and location and also with the same HIV serostatus, which may reflect serosorting and associated risk behaviors. Comparison of the two data sets suggests that the London epidemic involved about ten times more cases than the Sheffield outbreak., Importance: The recent increases in gonorrhea incidence and antibiotic resistance are cause for public health concern. Successful intervention requires a better understanding of transmission patterns, which is not uncovered by traditional molecular epidemiology techniques. Here we studied two outbreaks that took place in Sheffield and London, United Kingdom. We show that whole-genome sequencing provides the resolution to investigate direct gonorrhea transmission between infected individuals. Combining genome sequencing with rich epidemiological information about infected individuals reveals the importance of several transmission routes and risk factors, which can be used to design better control measures., (Copyright © 2016 Didelot et al.)

Data obtained from genitourinary medicine clinics through a comprehensive surveillance system were used in a Bayesian mixed-effects Poisson regression model to explore socio-demographic individual and ecological risk factors for gonorrhoea in London, as well as its spatial clustering. The spatial analysis was performed at the Middle-layer Super Output Area level (median population size 7200). A total of 12452 individuals were diagnosed during the 2-year study period (2009-2010). The study confirmed the presence of 'core areas' of high incidence, and identified 'core' high-risk groups, in particular young adults (16-29 years), males, black Caribbeans and more deprived areas. The individual (age, sex, ethnicity) and area-level (deprivation, teenage pregnancies, students) model covariates accounted for 48% of the variance. Most of the remaining variance was explained by the spatial effect, thus capturing other spatially distributed factors associated with gonorrhoea, such as local sexual networks. These findings will be useful in identifying areas for targeted interventions, such as STI testing and health promotion.

Introduction: There is uncertainty in the risk of pelvic inflammatory disease (PID) after chlamydia infection. We analyzed a prospective cohort of sex workers recruited in London between 1985 and 1993 to estimate the risk of PID after a diagnosed case of chlamydia., Materials and Methods: Chlamydia and gonorrhea were defined as "recent" if they occurred during the most recent 6 months of follow-up or "previous" if they were more than 6 months ago, were the second infection during follow-up, or occurred before the study. Pelvic inflammatory disease was diagnosed using clinical criteria. We used Cox proportional hazards regression to estimate the association between chlamydia and PID controlled for gonorrhea., Results: Three hundred seven women contributed 401.2 person-years of follow-up. The rate of PID in women with recent chlamydia was 27.4 per 100 person-years compared with 11.2 in those without recent chlamydia. Recent and previous chlamydia significantly increased the risk of PID; this association persisted but was no longer significant after controlling for age and history of gonorrhea: recent chlamydia (adjusted hazard ratio [aHR], 2.0; 95% confidence interval [CI], 0.7-5.5), previous chlamydia (aHR, 1.8; 95% CI, 1.0-3.5), previous gonorrhea (aHR, 2.3; 95% CI, 1.1-4.6), and age (HR, 0.9; 95% CI, 0.9-1.0)., Discussion: Women with recent or previous chlamydia are at increased risk for PID. However, this association may be explained by previous exposure to gonorrhea, which was found to increase the risk of PID after a future chlamydia infection.

Background: Despite antiretroviral therapy (ART), incident human immunodeficiency virus (HIV) continues to rise, and sexually transmitted infections (STI) are well known for their part in HIV transmission. National guidelines recommend routine STI screening in HIV-positive individuals, but despite this, reported uptake remains low., Methods: We implemented a nurse-led self-screening program for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in asymptomatic HIV patients. Self-collected samples were tested for CT and GC using the GenProbe Aptima Combo 2 assay. Clinical records were reviewed for ART history, CD4 T-cell count, and plasma viral load. A screening service evaluation questionnaire was handed out., Results: During an 8-month period, 976 screens were performed. In all, 143 infections were detected which would have been missed without the screening program. Overall prevalence of infection among men who have sex with men was 17.4%: rectal CT and GC, 9.8% (56/571) and 4.2% (24/571), respectively; urethal CT and GC, 2.6% (16/605) and 1.3% (8/605), respectively; and pharyngeal CT and GC, 1.7% (10/589) and 3.9% (23/589), respectively. Among heterosexual men and women, the rates of CT were 2.1% (3/141) and 1.5% (3/201), and there was no GC. Transient viremia was observed at the time of STI diagnosis in 6 patients on ART. All men who have sex with men and most women found self-swabbing acceptable, and most patients indicated that they would like to be offered testing in future., Conclusion: These findings highlight the need for the introduction of similar screening approaches in HIV clinics. Self-collected specimens using sensitive and specific GC and CT nucleic acid amplification tests are a convenient and acceptable way of testing, and it may address some of the barriers to screening in this population.

Objective: To analyse the enhanced data for gonorrhoea cases in England and Wales collected by the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) to better inform health policy and targeted interventions., Methods: GRASP data obtained annually from sentinel genitourinary medicine (GUM) clinics between June to August during 2001-6 were analysed., Results: A total of 12 282 cases of gonorrhoea were reported during the study period, with a decline over time primarily in heterosexual patients of black ethnicity. 73% of women, 47% of heterosexual men and 22% of men who have sex with men (MSM) were aged under 25. Most infected women reported a single sexual partner in the previous 3 months, whereas most heterosexual men and MSM reported two or more partners. A history of gonorrhoea was reported by 42% of MSM, 30% of heterosexual men and 20% of women. Excluding HIV, women were more likely than men to have a concurrent STI at diagnosis, most commonly chlamydia (50% vs 27% p<0.0005). Rectal gonococcal infections were reported in 35% and HIV co-infection in 31% of MSM. Compared to HIV negative MSM, those co-infected with HIV were older (median 35 years vs 28 years) and were more likely to attend a London site (70% vs 52%, p<0.0005); have a concurrent sexually transmitted infection (STI) (28% vs 20%, p = 0.002); have a history of gonorrhoea (66% vs 36%, p<0.0005) and have more sexual partners (average 6.8 vs 4.3)., Conclusion: Gonorrhoea is concentrated within specific groups who are at high risk of repeat infections and concurrent STIs including HIV. Targeted interventions of proved effectiveness are urgently required.

Objectives: To describe the prevalence and epidemiology of gonococcal infection in young subjects attending community clinics in South-East London., Methods: Subjects <25 years of age participating in the National Chlamydia Screening Programme were tested for gonococcal infection using a nucleic acid amplification test (strand displacement amplification assay)., Results: 10 523 tests were performed in 7369 patients (82% female) over a 2-year period in 2004 and 2005. Specimens used for tests were self-taken vulvovaginal swabs (43%), cervical swabs (40%), urine (16%) and urethral swabs (0.9%). Reasons for tests were: screening (67%), diagnosis (27%) and contacts of patients with chlamydia or gonococcus infection (7%). A significantly higher percentage of male subjects were tested as contacts (19% male vs 4% female; p<0.001). Of the 10 117 cases with definite results, 414 were positive (prevalence 4.1%, 95% CI 3.7% to 4.5%). There was a significantly higher prevalence in male subjects (5.7% male v 3.8% female; p<0.001). The average number of tests was 1.4 per patient (range 1-10). Contacts had a significantly higher prevalence (15.5%, p<0.001) than those tested for diagnostic (3.6%) or screening (3.1%) purposes. Multivariate regression analysis confirmed that there was a significantly higher prevalence in black Caribbean (5.8%, OR 2.44), black British/other black (5.6%, OR 2.33) and mixed (5.5%, OR 2.25) than white (2.4%) ethnic groups (p<0.001). Increasing age was significantly associated with lower prevalence (OR = 0.87; 95% CI 0.84 to 0.91; p<0.001). The odds of a positive test decreased by 13% for every year older., Conclusion: A community-screening programme has detected a high prevalence of Neisseria gonorrhoeae in South London, especially in teenagers, male subjects and certain ethnic groups.

Background: Gonorrhoea is an important cause of sexual ill health and is concentrated in geographical areas and demographic groups. This study explores the distribution of gonorrhoea across London., Methods: Epidemiological data on all gonorrhoea cases were collected from 13 major genitourinary clinics in London between 1 June and 30 November 2004. Samples were stored centrally and typed using NG-MAST. The postcode of each case's main residence was used to calculate incidence of gonorrhoea by borough using data from the UK 2001 census and a population survey on residence of men who have sex with men (MSM)., Results: 2,891 cases were confirmed, 1,822 of which had postcode data, resided in London, and had their strain successfully typed. There was a very high incidence of gonorrhoea in MSM (1,834 per 100,000 population) and heterosexuals of black ethnicity (392 per 100,000). The incidence among heterosexuals was highest in City of London (390 per 100,000, 95% CI 213 to 566), Southwark (308 per 100,000, 95% CI 280 to 336), Hackney (284 per 100,000, 95% CI 254 to 313), and Lambeth (216 per 100,000, 95% CI 194 to 239) and was not associated with measures of social deprivation (correlation coefficient = 0.0008, p = 0.97) but was strongly associated with black ethnicity (correlation coefficient = 0.48, p = 0.01). 45% of cases had one of the 21 major strains; eight of these strains were significantly clustered geographically and persisted for a shorter duration than those that were not clustered. Patients travelled a mean of 7.7 km from their home to the clinic., Conclusions: High gonorrhoea incidence in London is observed in MSM and heterosexuals of black ethnicity. Endemic strains in both MSM and heterosexuals are diagnosed at multiple clinics. Interventions, including partner notification, must therefore operate between clinics.

Background: Rates of bacterial sexually transmitted infections (STIs) continue to rise among men who have sex with men (MSM) in the UK., Objective: To evaluate factors associated with Chlamydia trachomatis and Neisseria gonorrhoeae among MSM attending a genitourinary medicine clinic in inner London., Study Design: 599 MSM undergoing testing for STIs were recruited. Specimens for ligase chain reaction (LCR), strand displacement amplification (SDA) assay and culture were collected from the pharynx, urethra and rectum for the detection of C trachomatis and N gonorrhoeae. Details regarding demographics, symptoms, signs and sexual behaviour were recorded. Associations of these factors with each infection were tested, adjusting for other risk factors., Results: The prevalence of C trachomatis and N gonorrhoeae was 11.0% and 16.0%, respectively. LCR and SDA performed well for the detection of C trachomatis and N gonorrhoeae from urethra and rectum. Using either method, compared with our current testing policy, over 18% of those with C trachomatis and N gonorrhoeae would not have had their infection diagnosed or treated. Age, sexual behaviour, urethral and rectal symptoms and signs were strongly associated with both infections. A total of 33.7% of men reported at least one episode of unprotected anal intercourse in the previous month. Men reporting multiple episodes were markedly more likely to be HIV positive., Conclusion: The prevalence of infection, rates of partner acquisition and unprotected anal intercourse reported among these MSM are alarming. Improved detection of C trachomatis and N gonorrhoeae using nucleic acid amplification tests has major public health implications for STI and possibly HIV transmission in this population.

Background: Molecular typing of Neisseria gonorrhoeae and contact tracing provide a combined approach for analysis of sexual networks in metropolitan areas, although there are some difficulties in application. Our aim was to examine the application of high-throughput molecular approaches that can identify individuals in linked sexual networks., Methods: We characterised 2045 isolates of N gonorrhoeae from patients presenting at 13 major sexually transmitted infection clinics in London, UK, between June 1 and Nov 30, 2004. All isolates were assigned a sequence type (strain) on the basis of the sequences of internal fragments of two highly polymorphic loci, por and tbpB. These types were matched to demographic and behavioural data obtained at the clinic for each patient. We assessed the congruence in the demographic and behavioural characteristics of individuals infected with the same strain., Findings: We identified 21 prevalent strains in this diverse gonococcal population, each infecting between 20 and 124 individuals. Seven of these strains were predominantly from men who have sex with men; the remaining 14 were predominantly from heterosexual people. No differences were recorded between the strains associated with men who have sex with men in the demographic or behavioural characteristics of infected individuals. By contrast, significant differences in age (p<0.0001), ethnicity (p=0.001), proportion of women (p=0.01), and HIV status (p=0.03) were noted between the 14 prevalent heterosexual-associated strains. Heterosexuals with strains not shared by others in the sample were significantly older (p=0.0005) and more likely to have had sex outside the UK (p<0.0001) than those sharing a strain with at least one other., Interpretation: The discriminatory high throughput strain characterisation method applied here identified localised transmission networks and suggests little bridging between networks of men who have sex with men and heterosexual networks.

Rectal gonorrhoea (GC) in men may cause anal discharge or proctitis, but these symptoms have been shown to correlate poorly with rectal infection. Culture of Neisseria gonorrhoeae from an exposed site offers a readily available, sensitive and cheap diagnostic test, and is currently the gold standard for diagnosis; however, these results can take a few days and therefore do not offer an instant diagnosis. Gram staining of rectal smears for N. gonorrhoeae has a low sensitivity but a high specificity when performed by experienced personnel. We audited whether rectal microscopy increased the number of patients diagnosed and treated for rectal GC at initial presentation at one inner London genitourinary clinic over a 12-month period. One hundred and thirty-six episodes of rectal GC were identified in 132 men. In all, 134/136 had rectal microscopy of whom, 47/134 (35%) were smear-positive for GC. Of the 136 cases, 90 received antibiotics for GC at their first presentation. Twenty-four of 90 (27%) would not have been treated until culture results were available, if rectal microscopy had not been performed. These results suggest that rectal microscopy remains an important tool and increases the proportion of men treated for GC at their first attendance.

The percentage of quinolone-resistant Neisseria gonorrhoeae isolated in London increased between 2000 and 2003, from 0.9% to 7.9% of total isolates. This increase was investigated by genotyping resistant isolates and comparing demographic and behavioral data. In 2000, resistant isolates predominantly had unique sequence types (STs) that were associated with imported infection, whereas, in 2002 and 2003, large ST clusters of indistinguishable isolates were associated with endemic acquisition. Resistant isolates that belonged to these large clusters were typically from patients who had similar epidemiological characteristics (such as ethnicity and sexual orientation) and behavioral characteristics (such as multiple sex partners and previous gonorrhea). In London, quinolone resistance is no longer associated with importation from areas of high prevalence and is spreading endemically in high-risk groups.

We studied the value of carrying out urethral samples in women to diagnose gonorrhoea. All cases of genital gonorrhoea in women were identified (between 1 October 2000 and 30 September 2001) at the Whittall Street Clinic and the genitourinary medicine department at the Coventry and Warwickshire Hospital. Two hundred and twenty-four cases of female urethral gonorrhoea were identified. In 20 cases (6.3%) the urethra was the sole site of the infection. At the Whittall Street Clinic, we had to carry out 643 urethral samples in order to treat one additional case of gonorrhoea. On the other hand, 1204 urethral samples were requested to treat one additional case of female gonorrhoea at the Coventry and Warwickshire Hospital. In both units, use of the Gram-stained urethral smear permitted early treatment in only 1.8% of cases of genital gonorrhoea. Units with low prevalence of gonorrhoea should consider abandoning urethral samples for the diagnosis of gonorrhoea in women.

The management and outcome of all cases of gonorrhoea which presented to a south London genitourinary medicine clinic during 1999 were assessed and compared with published national guidelines. The incidence of penicillin resistance was calculated, as was the rate of co-infection with chlamydia and trichomonas. Information regarding demographic data, microscopy, culture results, test of cure, antibiotic use, sensitivity and health adviser contact was examined. A total of 257 cases of gonorrhoea were diagnosed in 238 patients. Heterosexual men constituted 52.9% of cases, 6.6% were in homosexual men and 40.5% in women. Direct microscopy was positive in 88.8% of men and in 40.5% of women. In women, the rate of gonorrhoea co-infection with chlamydia was 34.7% and with trichomonas was 11.5%. In men the rate of chlamydia co-infection was only 3.3%, however, we do not believe this to be an accurate figure as we are unable to routinely screen all men for chlamydia due to financial restrictions. Amoxicillin with probenecid were the most commonly used antibiotics in line with local guidelines. Penicillin resistance was demonstrated in 4.6% of infected cases. Health advisers saw 73.2% of patients.

Objectives: To determine the true prevalence and patterns of resistance of Neisseria gonorrhoeae to antimicrobial agents used for therapy in London., Methods: A longitudinal study of a representative sample of isolates of N gonorrhoeae linked to demographic data of infected patients was undertaken. Isolates were collected from consecutive patients attending genitourinary medicine clinics in the North and South Thames regions of London during 3 months of each of 4 years, 1997-2000. Prevalence of plasmid mediated resistance to penicillin and chromosomally mediated resistance to penicillin and ciprofloxacin was determined by susceptibility testing. The association of antimicrobial resistance among gonococci with sexual orientation of the patient and country of acquisition of infection was determined., Results: Numbers of gonococcal isolates collected over the same time period between 1997-2000 have increased by 74%. Plasmid mediated resistance to penicillin was low but has risen above 5% in 2000. Chromosomal resistance to penicillin has fallen below the 5% level but total resistance to penicillin, plasmid and chromosomally mediated, was above 5% in all 4 years. The incidence of resistance and reduced susceptibility to the alternative therapeutic choice, ciprofloxacin, is low but numbers are increasing in each year. High level resistance, to both penicillin and ciprofloxacin, has generally been found among heterosexual men and is often acquired abroad. However, there is some evidence of a change to endemic spread in 2000., Conclusions: This surveillance programme shows that the epidemiology of gonorrhoea in London is changing with increasing numbers and changing patterns of resistance. If gonorrhoea is to be controlled and targets set by the sexual health strategy are to be met, intervention with effective and appropriate antimicrobial agents is essential.

Objectives: To examine differences in population based rates of gonorrhoea and chlamydia between black ethnic groups in Lambeth, Southwark and Lewisham Health Authority., Methods: Episodes of gonorrhoea or chlamydia recorded among attenders at 11 genitourinary clinics in south and central London from 1 January 1994 to 31 December 1995 were retrieved. Complete data on chlamydia were only available for women. Ethnic group was assigned according to census categories--white, black Caribbean, black African, black other, Asian, or other. We calculated yearly incidence rates for episodes of gonorrhoea and chlamydia in residents of Lambeth, Southwark and Lewisham Health Authority. Random effects Poisson regression models were used to examine associations between infection rates and age, ethnic group, and material deprivation., Results: During the study period there were 1996 episodes of gonorrhoea in men and women and 1376 episodes of chlamydia in women with complete data. For both infections rates among individuals from black Caribbean and black other ethnic groups were markedly higher than among black Africans. In men, the gonorrhoea rate among black Caribbean 20-24 year olds was 2348 (95% CI 1965 to 2831) episodes per 100,000 compared with 931 (95% CI 690 to 1288) in black African men and 111 (95% CI 100 to 124) per 100,000 in white men of the same age. Among women gonorrhoea rates were highest in black Caribbean 15-19 year olds (2612, 95% CI 2161 to 3190 per 100,000). In contrast, rates in black African women of the same age (331, 95% CI 154 to 846 per 100,000) were similar to those of white women (222, 95% CI 163 to 312). Chlamydia rates were also highest in black Caribbean 15-19 year old women (4579, 95% CI 3966 to 5314 per 100,000), compared with 1286 (95% CI 907 to 1888) in black African and 433 (95% CI 349 to 544) per 100,000 white women. Controlling for material deprivation and age only attenuated differences in rates between ethnic groups slightly., Conclusions: There are marked differences in rates of gonorrhoea and chlamydia between different black ethnic groups, with higher rates in black Caribbeans than black Africans. This study supports the hypothesis that assortative sexual mixing patterns can restrict epidemics of sexually transmitted infections within ethnic groups. Differences in disease occurrence between black ethnic groups should be explored before combining data, even when numbers of episodes are small.

Our objectives were to determine the prevalence of Neisseria gonorrhoeae not fully sensitive to ciprofloxacin from a sexually transmitted infection (STI) clinic in London and where the isolates were acquired from. Data of antibiotic sensitivities of N. gonorrhoeae from 292 patients were reviewed over a 6-month period at St Mary's Genitourinary Medicine (GUM) Clinic, London. Isolates which exhibited reduced susceptibility (minimum inhibitory concentration [MIC] 0.03-0.12 mg/l) and high level resistance (MIC>0.12 mg/l) to ciprofloxacin represented 10% and 1.3% of the total respectively. All patients infected with a high level resistant isolate to ciprofloxacin had had a recent sexual partner from abroad but 18 of the 28 patients infected with a reduced susceptibility isolate denied recent travel. None of the 20 patients with a non-sensitive isolate who re-attended for post treatment cultures had persistant gonococcal infection. From this study we concluded that although N. gonorrhoeae resistant to ciprofloxacin was rare and probably always acquired abroad, isolates exhibiting reduced susceptibility were more common and were mainly as a result of infection from the UK. A stat dose of ciprofloxacin 500 mg and doxycycline 100 mg twice a day for one week was effective treatment.

Background: Gonorrhoea is a common infectious disease, poorly controlled despite effective treatments. Tracing chains of transmission is difficult, because sexual partners are commonly difficult or impossible to identify. We assess the use of gonococcal opa-typing in identifying transmission links not revealed through interview., Methods: Epidemiological data and gonococcal isolates were collected prospectively from patients at two UK clinics in London and Sheffield. Social and epidemiological data were combined with molecular typing of gonococcal isolates by a new methodology based on the polymorphisms of the opa gene., Findings: In London, interview data and opa-typing on samples from 215 cases showed a diverse population with few links. In Sheffield, interview data identified links between 51 (43%) of 120 cases, whereas opa-typing suggested a more connected population: 95 (79%) of cases had shared profiles. There was a highly significant correlation between the two distributions with epidemiological clusters appearing as a subset of the opa clusters. Two large opa clusters, of 18 and 43 cases, accounted for 50% of local cases of gonorrhoea. Discordance between epidemiological and opa-typing data was observed at highly connected points in the sexual network., Interpretation: Opa-typing is a more powerful tool for epidemiological investigation of gonorrhoea transmission than earlier methods. Opa-typing can link infections that would otherwise remain unlinked, and may aid interventions to control endemic disease.

We studied 180 black heterosexual men of whom 133 (74%) were Caribbean and 47 (26%) African. Seventy-three per cent of Caribbeans and 27% of Africans were UK born. We found no difference in age, but more Africans were married (30% cf 10%; P=0.002) and students (26% cf 10%; P=0.00008). More Caribbeans smoked 1-10 cigarettes a day (42% cf 22%; P=0.02) and more drank alcohol (89% cf 74%; P=0.002). Sixty-nine per cent of Caribbeans reported intercourse before the age of 17 compared with 48% of Africans (P=0.004), but there was no difference in the numbers of sexual partners, either in the previous year or in total. Twenty-four (18%) of the 133 Caribbeans had gonorrhoea compared with one (2%) of the 47 Africans (P=0.001). Multivariate analysis showed that coitarche under 16 years of age (odds ratio (OR) 50) and gonococcal and/or chlamydial infection (OR 12.5) were independently associated with Caribbeans. Within this group, gonorrhoea was found more often in teenagers (OR 9.5) who had commenced intercourse before the age of 16 (OR 3.3) and chlamydial infection in those with multiple partners (OR 24). New problem-orientated approaches are needed to eradicate these curable infections which facilitate infection with HIV.

The results of a one-year clinical, epidemiological and microbiological survey of gonococcal infection presenting to the Patrick Clements Clinic (PCC), a London district general hospital (DGH) genitourinary medicine (GUM) clinic, are presented. Clinical and epidemiological patient data were collected by a combination of questionnaire and retrospective case-note review. Microscopy performance within the PCC, outcome of treatment, return for tests of cure and efficacy of contact tracing were assessed. Isolates were tested for susceptibility to penicillin, tetracycline and ciprofloxacin. The study showed the PCC continues to diagnose and treat over 200 cases of gonorrhoea per year. High level resistance to penicillin, tetracycline and ciprofloxacin was documented among the year's isolates and antibiotic resistance was linked to acquisition of gonorrhoea overseas. Despite interviewing 183 patients concerning health advice and contact tracing issues, only 55% of new episodes re-attended for a first test of cure. In addition, only 29% of reported sexual contacts attended GUM clinics for investigation and treatment.

Background: Our aim was to describe surveillance data on HIV transmission and risk behaviours in Camden and Islington, an inner London health district (population 360 000). This information is required to assess the effectiveness of HIV-AIDS prevention., Methods: We focused on two groups in the local population most severely affected by the HIV epidemic: homosexual and bisexual men, and injecting drug users. Data were drawn from routine and survey data, national and local sources, and a special local survey., Results: There were estimated to be 9250 homosexual men, with an estimated prevalence of 7.7 per cent (confidence interval (CI) 5.9-11.0) diagnosed with HIV infection resident within the health district, and 9900 injecting drug users, with an estimated prevalence of 0.8 per cent (CI 0.6-1.1), diagnosed with HIV infection. New HIV infections diagnosed amongst homosexual men having a named test in HIV testing services averaged 281 and was unchanged between 1992 and 1996. However, unlinked anonymous seroprevalence surveys showed a decline in HIV prevalence for both homosexual men attending a genito-urinary medicine clinic and for injecting drug users attending services. Local surveys indicated that, in the preceeding year, one in three homosexual men had had unprotected anal intercourse with a man, and 13 per cent of intravenous drug users had shared equipment. There appeared to be no change in these levels over the years studied., Conclusion: Population-based information on HIV is available at local level in England. It can be used for surveillance of HIV transmission and behaviour in high-risk groups, especially homosexual and bisexual men and intravenous drug users. Resources for HIV prevention are provided to all NHS districts, and surveillance is a cost-effective measure of the outcome of HIV prevention.

Objectives: To establish the in vitro susceptibility of gonococci isolated in the London area to antibiotics in current therapeutic use and to establish a sentinel surveillance system for monitoring trends in antibiotic resistant gonorrhoea in London., Methods: Isolates of Neisseria gonorrhoeae from consecutive patients attending genitourinary medicine clinics at 10 hospitals in the London area were collected over a 3 month period, May to July 1997. The susceptibility to penicillin, ciprofloxacin, tetracycline, and spectinomycin was determined for each isolate. Isolates exhibiting either plasmid or chromosomally mediated resistance were additionally tested for susceptibility to agents used as alternative treatments including azithromycin, ceftriazone, and ofloxacin. The resistant isolates were also tested for plasmid profiles (penicillinase producing N gonorrhoeae, PPNG), type of tetM determinant (tetracycline resistant N gonorrhoeae, TRNG), and presence of gyrA and parC mutations (quinolone resistant N gonorrhoeae, QRNG)., Results: A total of 1133 isolates were collected which represents > 95% of the total gonococci isolated in the 3 months. Plasmid mediated resistance was exhibited by 48 (4.2%) isolates; six (0.5%) were PPNG, 15 (1.3%) were PP/TRNG, and 27 (2.4%) were TRNG. The majority of PPNG (18 of 20 tested) carried the 3.2 MDa penicillinase plasmid whereas the two types of tetM determinant were more evenly distributed. High level resistance to ciprofloxacin was detected in four (0.4%) isolates and double mutations were found in the quinolone resistance determining region (QRDR) of the gyrA gene in three QRNG with MICs of 16 mg/l and a single mutation in one isolate with a MIC of 1 mg/l to ciprofloxacin. No parC mutations were found. Of the remaining 1081 isolates, 86 (8.0%) were chromosomally mediated resistant N gonorrhoeae (CMRNG)., Conclusions: A unique collection of gonococcal isolates has been established which can be used as a baseline for surveillance of susceptibility to antibiotics and for epidemiological purposes.

It is well known that arthritis can be associated with venereal disease. Nowadays septic arthritis and reactive arthritis (usually classified as Reiter's syndrome) are distinguished. To place current knowledge within its historical context we reviewed the medical literature on sexually acquired arthritis in the nineteenth century and examined the medical records of London teaching hospitals from this period. We used original sources of rheumatological literature at major London libraries, including the Heberden library of the Royal College of Physicians, and visited the archives at three London teaching hospitals to review original case records and examine diagnostic registers. The first clear description of arthritis associated with venereal disease was given by Swediaur (1798/1809) in French. It became relatively common in London from 1820 onwards with 13 cases described in the literature between 1818 and 1836. It accounts for 3% of admissions at University College and St Bartholomew's Hospitals between 1835 and 1839 and also 3% of admissions at the London Hospital from 1895 to 1900. In the 50 years after Swediaur's report, arthritis associated with venereal disease seemed quite common. This may have been related to the industrial revolution or other social diseases. Historical observations suggest its evidence may vary considerably with time.

Objectives: To estimate population based incidence rates of gonorrhoea in an inner London area and examine relations with age, ethnic group, and socioeconomic deprivation., Design: Cross sectional study., Setting: 11 departments of genitourinary medicine in south and central London., Subjects: 1978 first episodes of gonorrhoea diagnosed in 1994 and 1995 in residents of 73 electoral wards in the boroughs of Lambeth, Southwark, and Lewisham who attended any of the departments of genitourinary medicine., Main Outcome Measures: Yearly age, sex, and ethnic group specific rates of gonorrhoea per 100,000 population aged 15-59 years; rate ratios for the effects of age and ethnic group on gonorrhoea rates in women and men before and after adjustment for confounding factors., Results: Overall incidence rates of gonorrhoea in residents of Lambeth, Southwark, and Lewisham were 138.3 cases yearly per 100,000 women and 291.9 cases yearly per 100,000 men aged 15-59 years. At all ages gonorrhoea rates were higher in non-white minority ethnic groups. Rate ratios for the effect of age adjusted for ethnic group and underprivilege were 15.2 (95% confidence interval 11.6 to 19.7) for women and 2.0 (1.7 to 2.5) for men aged 15-19 years compared with those over 30. After deprivation score and age were taken into account, women from black minority groups were 10.5 (8.6 to 12.8) times as likely and men 11.0 (9.7 to 12.6) times as likely as white people to experience gonorrhoea., Conclusions: Gonorrhoea rates in Lambeth, Southwark, and Lewisham in 1994-5 were six to seven times higher than for England and Wales one year earlier. The presentation of national trends thus hides the disproportionate contribution of ongoing endemic transmission in the study area. Teenage women and young adult men, particularly those from black minority ethnic groups, are the most heavily affected, even when socioeconomic underprivilege is taken into account. There is urgent need for resources for culturally appropriate research and effective intervention to prevent gonococcal infections and their long term sequelae in this population.

This paper compares the socio-demographic characteristics of patients with gonorrhoea with a control group of other attendees to an inner-London genitourinary medicine (GUM) clinic. Between 16 May and 21 December 1994 inclusive there were 312 culture-confirmed heterosexually-acquired cases of Neisseria gonorrheae treated in our clinic: 192 (61.54%) men and 120 (38.46%) women. There were significant differences between the population of cases and controls. Both male (z = -5.36, P < 0.001) and female (z = -6.6, P < 0.001) cases were younger than controls. Cases were more likely to be black African-Caribbean than were controls and these differences were more marked in men (chi 2 = 47.85, P < 0.001). Cases were also more likely to reside in south London postal districts than were controls (chi 2 = 24.98, P < 0.001). The implications of these findings for targeted health interventions are discussed and we suggest avenues for further work.

Objective: To describe the epidemiology and associated clinical features of gonorrhoea and chlamydial infection and to develop a profile of sexually transmitted diseases (STDs) in an outer London health district., Design: Hospital-based retrospective study., Setting: Genitourinary medicine clinic, Northwick Park Hospital, Harrow and Brent Health Authority., Subjects: 70 male and female individuals with gonorrhoea and 129 with chlamydial infection, diagnosed consecutively over 28 months in 1992-94., Results: More men than women had gonorrhoea (43 versus 27) but more women than men had chlamydial infection (84 versus 45), p < 0.001. There was a clear tendency for cases with either infection to locate along major road and rail transport routes. Foci of gonococcal infection were concentrated mainly in the densely populated areas, whereas chlamydial cases were more evenly spread. There was no significant effect of gender or type of STD on the odds ratio for residence in Harrow, single marital status or attendance for test of cure. However, the odds ratios for women having sexual intercourse with a regular partner only or previous STD were 5 (95% CI 2.4 to 10.2), p < 0.001 and 0.3 (95% CI 0.18 to 0.69), p = 0.002 times the odds for men, respectively. The odds ratios for patients with gonococcal infection being employed or having sex with a regular partner only were 0.5 (95% CI 0.27 to 0.98), p = 0.04 and 0.30 (95% CI 0.15 to 0.60), p < 0.001 times the odds for patients with chlamydial infection, respectively. Of the women with gonorrhoea and previous pregnancy, 68% gave a history of abortion compared with 44% of those with chlamydial infection (p = 0.03)., Conclusion: The identification of foci gonococcal and chlamydial infection and apparent location of these infections along the major transport routes in our health district require further study. That chlamydial infection, unlike gonorrhoea, is evenly distributed irrespective of population concentration and deprivation, suggests urgent need for a comprehensive local effort to control both STDs.

Patients who acquire repeated infections of gonorrhoea are well described. A study was undertaken of male patients attending a central London clinic in an attempt to identify features of those acquiring repeated infections to facilitate risk reduction strategies. During the 3 years 1990 to 1992, 18.8% of patients contributed 35.8% of episodes with a mean time between episodes of 10.5 weeks. Those with repeat infections were more likely to be black and to have had more than one episode of gonorrhoea prior to the study period. They are also more likely to have had 3 or more recent partners. While those with repeated infections do not form a homogeneous group there are certain characteristics that should enable targeting of a subgroup.

Study Objectives: To describe mathematically the relationship between patterns of sexual mixing in the general population and those of people with gonorrhoea infection, and hence to estimate the sexual mixing matrix for the general population., Design: Integration of data describing sexual behaviour in the general population, with data describing sexual behaviour and mixing among individuals infected with gonorrhoea. Use of these data in a simple mathematical model of the transmission dynamics of gonorrhoea infection., Setting: The general population of London and a genitourinary medicine (GUM) clinic in west London., Participant: These comprised 1520 men and women living in London who were randomly selected for the national survey of sexual attitudes and lifestyles and 2414 heterosexual men and women who presented to the GUM clinic with gonorrhoea., Main Results: The relationship between sexual mixing among people with gonorrhoea and sexual mixing in the general population is derived mathematically. An empirical estimate of the sexual mixing matrix for the general population is presented. The results provide tentative evidence that individuals with high rates of acquisition of sexual partners preferentially select other individuals with high rates as partners (assortative mixing)., Conclusions: Reliable estimates of sexual mixing have been shown to be important for understanding the evolution of the epidemics of HIV infection and other sexually transmitted diseases. The possibility of estimating patterns of sexual mixing in the general population from information routinely collected in gonorrhoea contact tracing programmes is demonstrated. Furthermore, the approach we describe could, in principle, be used to estimate the same patterns of mixing, using contact tracing data for other sexually transmitted diseases, thus providing a way of validating our results.

Objectives: To collect epidemiological data on gonococcal infection in an east London genitourinary medicine (GUM) clinic; to perform antibiotic susceptibility testing on Neisseria gonorrhoeae isolates and relate results to patient data; to assess the efficacy of current first-line antibiotic therapy for treating gonorrhoea., Methods: Gonococcal isolates were collected from 113 patients attending the GUM clinic at Newham General Hospital over a one year period. Isolates (104) were tested for susceptibility to various antibiotics. Plasmid profiles were obtained for penicillinase producing gonococci (PPNG) and isolates exhibiting high-level tetracycline resistance (TRNG). Epidemiological information was collected from clinic attenders by routine note-taking., Results: PPNG (16) accounted for 15% of isolates tested, only three being acquired outside the United Kingdom (U.K.). Plasmid typing showed three types of beta-lactamase-encoding plasmids were represented (2.9 MDa, 3.2 MDa and 4.4 MDa). Amongst the non-PPNG isolates, high-level chromosomal resistance to penicillin (CMRNG) was found in 3.5%, intermediate resistance in 57.5% and full susceptibility in 39%. One isolate showed decreased susceptibility to ciprofloxacin (MIC = 0.06 mg/l). Three PPNG isolates also possessed a 25.2 MDa plasmid and expressed high-level tetracycline resistance encoded by tetM. All isolates were susceptible to cefixime, cefotaxime, azithromycin and spectinomycin. Most gonorrhoea (90%) was seen in local residents. The male:female case ratio was 2:1 with homosexually-acquired gonorrhoea accounting for only 3.5% of the total. Most patients (96%) had acquired gonorrhoea in the U.K.. A past history of gonorrhoea was more frequent in male patients. Concurrent chlamydial infection was seen in 31% females and 16% males., Conclusions: The high PPNG rate supports a previous decision to change first-line therapy from amoxycillin with probenecid to ciprofloxacin. There was no evidence of clinical treatment failure with ciprofloxacin. Cefixime, cefotaxime, azithromycin and spectinomycin all appear to be suitable alternative therapies. Acquisition of gonorrhoea abroad was associated with isolates exhibiting penicillin resistance but such isolates were also obtained from patients infected locally and without a history of foreign travel.

Between 1986 and 1992, 15% of all cases of penicillinase-producing Neisseria gonorrhoeae (PPNG) notified in the UK were seen at our central London clinic. During this time the geographical provenance of PPNG has changed. Africa and SE Asia have been supplanted by the Caribbean as the predominant source, with 21.4% of all cases being directly imported from there in 1992. If all gonococcal infections acquired outside the UK had been assumed to be PPNG, together with those occurring in patients with family origins in Africa or SE Asia, some 60% of cases of PPNG could have been predicted before laboratory confirmation of resistance. There is little evidence that PPNG has become endemic in the United Kingdom.

Objective: To describe and discuss the trends in the isolation of Neisseria gonorrhoeae from patients attending the Genitourinary Medicine Clinic at St. Mary's Hospital, Paddington, London between 1980 and 1991., Design: A retrospective study of the total number of gonococci isolated over an eleven year period was performed. In addition, for the years 1988-1991 the number of isolates from homosexual men was analysed by age of the patient, site of infection and HIV antibody status of the patient., Results: The total number of N. gonorrhoeae isolates identified declined markedly between 1980 and 1989 from 3670 to 750 isolates. Over the same time period the number of specimens screened for N. gonorrhoeae fell by 50%. In 1990 there was an increase in N. gonorrhoeae isolates but this was not maintained, and in 1991 the number of N. gonorrhoeae fell to its lowest level of 638 isolates. The decrease since 1980 occurred in both men and women although the number of rectal isolates from men showed a steeper decline reaching its lowest level of 24 isolates in 1988. The number of rectal isolates from homosexual men has since increased with a peak in 1990. Many of the infections among homosexual men occurred in older men and included insignificant number of patients who were HIV positive., Conclusion: Gonorrhoea among attenders at St. Mary's Hospital has declined dramatically since 1980 following trends reported from much of Europe. The increase in gonococcal isolates since 1989 and the peak in 1990 are unexplained but are coincident with a higher number of isolates from homosexual men.

Objectives: To determine the prevalence of infection with HIV-1, HIV2, HTLV-1 and HTLV-2 in female attenders at a central London sexually transmitted disease clinic in an 8 week period in 1989-1990, and compare it with similar samples studied between 1985 and 1987., Design: Anonymous testing of serum samples from consecutive female patients having routine serological investigation for syphilis. Testing was for clinically important retroviruses, Hepatitis B core antibodies (anti-HBc), and p24 and reverse transcriptase (RT) antigens. Age (in 5 year bands), nationality (in broad geographical zones), diagnosis on the day of presentation, and history of intravenous drug usage were recorded for each patient. Annual gonorrhoea rates were analysed from 1981 to 1990., Setting: Outpatients of the department of genitourinary medicine., Patients: A total of 850 females attending consecutively and having routine syphilis serology., Main Results: The prevalence of anti-HIV-1 in female attenders in 1989-1990 was 0.35% (3/850). Prevalence in the same clinic has remained statistically unchanged since the first female cases were identified in 1986. No cases of HIV-2, HTLV-1 or HTLV-2 were identified, and no early HIV-1 infection evidenced by the presence of p24 or RT antigenaemia was found. Female gonorrhoea rates continued to decline but other STD monthly/annual rates have remained unchanged., Conclusions: Over the last 5 years prevalence of HIV-1 infection in females in our clinic has remained unchanged and other retroviral infections have remained absent. However, the unaltered rates of other genital infections, their potential role in the heterosexual spread of HIV-1 infection, and the lack of evidence for any major changes in female sexual behaviour suggests there is a need to remain vigilant. This work complements the MRC multicentre, unlinked, genitourinary medicine clinic, anonymous testing programme, and our group will continue to apply this simple methodology to specimens from female attenders to contribute to the surveillance of the evolving HIV-1 epidemic.