Angela Robinson

Chlamydia trachomatis and Neisseria gonorrhoeae infection and the sexual behaviour of men who have sex with men

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.

Comparison of two methods of screening for genital chlamydial infection in women attending in general practice: cross sectional survey

Abstract Objectives: To estimate the prevalence of Chlamydia trachomatis in asymptomatic women attending general practice; to assess the potential of the ligase chain reaction as a screening tool; and to evaluate selective screening criteria. Design: Cross sectional survey. Setting: Four general practices in northeast London. Subjects: 890 women aged 18-35 years attending general practice for a cervical smear or a “young well woman” check between October 1994 and January 1996. The women were tested for C trachomatis with confirmed enzyme immunoassay (endocervical specimens) and ligase chain reaction assay on urine specimens. Main outcome measures: Prevalence of C trachomatis infection in women aged 18-35 on the basis of each test; sensitivity and specificity of both tests in this population. Results: Prevalence of confirmed infection was 2.6% (95% confidence interval 1.6% to 3.6%) in all women. Prevalence on the basis of enzyme immunoassay was 1.6% (0.8% to 2.7%), with a sensitivity of 60% and a specificity of 100%. Prevalence on the basis of ligase chain reaction was 2.5% (1.5% to 3.9%), with 90% sensitivity and 99.8% specificity. Screening all women aged ≤25 and all women who had had two or more partners in the past year would have detected 87% (20/23) of infections. Conclusion: Ligase chain reaction on urine samples performs at least as well as enzyme immunoassay on cervical specimens in this low prevalence population. It offers potential as a non-invasive screening tool. A simple selective screening strategy might be appropriate and would be able to detect most cases of infection. However, a rigorous economic evaluation of possible screening strategies is needed first. Key messages Chlamydia trachomatis causes a common sexually transmitted infection, which is often asymptomatic but may lead to pelvic inflammatory disease, ectopic pregnancy, and tubal infertility in 10%-25% of infected women Over 1 in 20 women aged 18-25 years attending general practice may have undiagnosed infection New screening tests that do not require a cervical sample should improve the prospects for community based screening for chlamydia Rigorous evaluation of the cost effectiveness of such screening is now a priority

Home screening for chlamydial genital infection: is it acceptable to young men and women?

Objectives: To determine the acceptability, to young men and women, of home screening for chlamydial infection. Methods: We wrote to a random sample of 208 women aged 18–25 years and 225 men aged 18–35 years from three general practices, inviting them to undergo home screening for chlamydial infection. They were asked to return, by normal post, a urine specimen (for men and half of the women) or a vulval swab (other half of the women) for ligase chain reaction (LCR) testing for chlamydial infection. They were also asked to return a short questionnaire about risk status and the acceptability of this approach. Results: The participation rate among the available sample was 39% for women and 46% for men (p=0.3). However, among women, the rate was slightly higher (p=0.05) for urine samples (47%) than for vulval swabs (32%). Six per cent of women and 9% of men declined to take part, while 42% of women and 33% of men failed to respond. Two men objected to receiving the package at home. We received few other comments, positive and negative in about equal measure. Conclusion: Home screening for chlamydial infection is a potentially efficient method of reaching young people who may have little contact with health services. Men were at least as likely as women to respond to this screening approach. Home screening might form a useful component of a future chlamydial screening programme in the United Kingdom.

Evaluation of self-taken samples for the presence of genital Chlamydia trachomatis infection in women using the ligase chain reaction assay

The aim of this study was to evaluate the sensitivity and acceptability of self-taken vulval-introital (VI) samples, first-catch urine (FCU) samples and clinician-obtained cervical samples for the presence of genital Chlamydia trachomatis infections in women using the ligase chain reaction (LCR) assay. One hundred and four patients were enrolled, of whom 54 patients had chlamydial DNA in at least one of the samples tested. The sensitivity of the cervical sample was 96.3%, vulval-introital sample in LCR buffer 92.6%, vulval-introital swab collected dry 88.9%, FCU stored at +2–8°C 81.5%, FCU stored at room temperature 77.8% and FCU stored with 2% w/v boric acid at room temperature 87.0%. Self-taken vulval-introital LCR samples were shown to be an acceptable alternative to a clinician-obtained LCR sample. The addition of boric acid may overcome the need for a continuous cold chain for FCU samples.

Implications of inflammatory changes on cervical cytology.

OBJECTIVE--To assess premenopausal women with inflammatory changes on cervical cytology for genital infections and cervical abnormalities. DESIGN--Prospective study of women attending general practice and family planning clinics who had a recent cervical cytology result with inflammatory changes. SETTING--Department of genitourinary medicine. PATIENTS--102 Premenopausal women with recent cytology result showing inflammatory changes and with no history of antibiotic or antifungal treatment since their smear. INVESTIGATIONS--Genital examination and microbiological screening for genital infections; colposcopic examination about six weeks later. MAIN OUTCOME MEASURES--Detection of genital infections, particularly those sexually acquired, and abnormalities on colposcopy. RESULTS--Genital infections were isolated in 77 patients, and one or more sexually acquired infections were found in 22. Prevalence of sexually acquired infections was significantly correlated with younger age (particularly being under 25), being single, separated, or divorced; using non-barrier contraception; and recent change of sexual partner. An abnormality on colposcopy was found in 36 women. There was a strong correlation of a sexually acquired infection with an abnormality at colposcopy; hence younger women were more likely to have a colposcopic abnormality. CONCLUSIONS--Inflammatory changes on cytology are often associated with the presence of a sexually acquired infection and premalignant disease of the cervix, particularly in younger, single women using non-barrier contraception.

UK National Guideline on the Management of Sexually Transmitted Infections and Related Conditions in Children and Young People (2009)

This guideline is appropriate for use in genitourinary (GU) medicine/sexually transmitted infections (STIs) clinics, and by other National Health Service (NHS) or other services providing sexual health advice, management or treatment to young people, e.g. sexual health clinics, young person’s clinics, contraceptive clinics, gynaecology/antenatal services, termination services, Sexual Assault Referral Centres (SARCs), paediatric services and general practice in the UK. The principles apply wherever young people are seen for sexual health care or where there are concerns about child sexual abuse (CSA) or where a STI has been detected. It includes recommendations on the assessment, examination, diagnostic tests, treatment regimens and prophylaxis for the effective management of children and young persons under 16 at risk of, or who have, an STI. It offers guidance on consent and confidentiality on children and young people presenting to health-care professionals working in sexual health services. It is also applicable to young people aged 16–18 who have learning difficulties or who are ‘vulnerable’. Some parts of the guidelines are relevant to all those providing sexual health services, but other parts are only relevant to Level 3 service providers. Prevention of STIs through health education and one-to-one interventions as recommended by the National Institute of Health and Clinical Excellence (NICE) is an integral part of sexual health care of young people but is outside the scope of the guidelines. Stakeholder involvement, rigour of development, levels of evidence and grading of recommendations are available online only in the full version of this guideline at http://ijsa.rsmjournals.com/cgi/content/full/21/4/229/DC1 This guideline is laid out in specific sections: Part 1: Introduction and discussion of issues concerning consent, confidentiality, child protection and basic principles of care. Part 2: The diagnosis and management of specific STIs and related conditions in the under 16s. Correspondence to: K Rogstad

National study of HIV testing in men who have sex with men attending genitourinary clinics in the United Kingdom.

Objectives: To determine what proportion of men who have sex with men (MSM) attending genitourinary medicine (GUM) clinics are offered and accept an HIV test and to examine clinic and patient characteristics associated with offer and uptake. Methods: A cross-sectional study of all GUM clinics in the United Kingdom, involving a case note review of up to 30 patient records per clinic and the completion of a clinic policy form. Results: Overall, 86% of MSM were offered a test and of those 82% accepted a test. Attending with symptoms of a sexually transmitted infection (STI), fewer numbers of partners in the past three months and having tested previously were all independently associated with a decreased likelihood of being offered a test. Attending with symptoms of an STI, increasing age, never having had a risk from unprotected anal intercourse or a previous HIV test and increasing time to wait for results were all independently associated with a decreased likelihood of a patient accepting a test. Only a quarter of clinics reported a written policy for HIV testing intervals among MSM; however, all clinics reported offering testing to all new MSM patients at first screening. The testing policy for re-attending patients was less clear. Conclusions: Testing must reach those at most risk and those less likely to test in order to reduce further the proportion of undiagnosed HIV infection. This study suggests that opportunities to detect infection may be being missed and a move towards universal testing of all MSM attending with a new episode, as well as testing within the window period, is recommended.

‘Talking of Sex’: Developing and piloting a sexual health communication tool for use in primary care

OBJECTIVE To develop and pilot a communication aid aimed at increasing the frequency with which sexual health issues are raised proactively with young people in primary care. METHODS Group interviews among primary health care professionals to guide development of the tool, simulated consultations to pre-test it, and a pilot study to assess effectiveness. RESULTS We developed an electronic consultation aid: Talking of Sex and piloted it in eight general practices across the UK. 188 patients and 58 practitioners completed questionnaires pre-intervention, and 92 patients and 45 practitioners post-intervention. There was a modest increase in the proportion of consultations in which sexual health was raised, from 28.1% pre-intervention to 32.6% post-intervention. In consultations with nurses the rise was more marked. More patients reported discussing preventive practices such as condom use post-intervention. Patients unanimously welcomed the opportunity to discuss sexual health matters with their practitioner. CONCLUSION The tool has capacity to increase the frequency with which sexual health is raised in primary care, particularly by nurses, to influence the topics discussed, and to improve patient satisfaction. PRACTICE IMPLICATIONS The tool has potential in increasing the proportion of young people whose sexual health needs are addressed in general practice.

Concurrent gonococcal and chlamydial infection: how best to treat.

Clinicians treating concurrent gonococcal and chlamydial infections have a variety of drugs to choose from. Neisseria gonorrhoeae is adept at developing resistance and the choice of antibiotic must be dictated to some extent by the patterns of resistance in the locality of the clinician. In contrast, resistance of Chlamydia trachomatis to some classes of drugs has been shown in vitro but does not appear to be clinically important at present.The success of treatment depends on patient compliance with the drug administration schedule. With these organisms, which can be carried asymptomatically, many patients are unlikely to comply with courses of antibiotics.Although single-dose therapy with azithromycin is available and established for chlamydial genital infection, it is more expensive and difficult to justify in a cash limited Healthcare system, and its efficacy for treating concurrent gonococcal infection requires further study. In patients where compliance is likely to be of concern, its use may be justified.Another major deterrent for completing antibiotic courses is the adverse effect profile. Most of the available drugs cause only minor adverse effects, in particular gastrointestinal. Ofloxacin has a better profile than doxycycline but is considerably more expensive. Newer fluoroquinolones, found to be effective in vitro, are being assessed in clinical studies. However, more evidence is required before recommending these over the tried and tested therapies.

National guideline for the management of suspected sexually transmitted infections in children and young people

The Children Act 19891 defines a child as “a person who has not yet reached 18 years of age.” In England, Wales, and Scotland the present age of consent for heterosexual and homosexual sex is 16 years and in Northern Ireland it is 17 years. The proportion of young people who report heterosexual intercourse before the age of 16 years increased in the 1990s compared with the previous decade.2