E Foley

Relationship of cervical ectopy to chlamydia infection in young women

Objective Genital Chlamydia trachomatis infection is the most common bacterial sexually transmitted infection (STI) in the UK. Behaviours including multiple sex partners and inconsistent condom use, and biological factors such as cervical ectopy, may increase susceptibility to STIs. Cervical ectopy is thought to increase risk of chlamydia infection by exposing columnar epithelium to a potential infectious inoculum. This study aimed to determine whether chlamydia was more prevalent in young women with cervical ectopy. Methods Clinical notes of women aged 16–24 years attending the Portsmouth Genitourinary Medicine Clinic for an STI screen during the period May–July 2003 were reviewed retrospectively. Information collected included the presence or absence of cervical ectopy, smoking habits, methods of contraception, number of sexual partners in the previous 3 months, and previous STIs. Chlamydia infection was diagnosed by using strand displacement amplification on cervical swabs. Results A total of 231 women were included in the study. The mean age was 19.8 years. Evidence of cervical ectopy was found in 107 women. Chlamydial infection was detected in 37.4% (40/107) of those women with cervical ectopy and 21.8% (27/124) in those without cervical ectopy. This difference was statistically significant (p = 0.009). The significance remained even when accounting for confounding variables. Conclusions Cervical ectopy is a common physiological process in young women. Recognition of cervical ectopy should alert the clinician to the possibility of a genital chlamydia infection. Opportunistic screening for chlamydia in young people should be offered to reduce the prevalence of infection and its sequelae.

2014 UK national guideline for the management of anogenital herpes

These guidelines concern the management of anogenital herpes simplex virus infections in adults and give advice on diagnosis, management, and counselling of patients. This guideline replaces the 2007 BASHH herpes guidelines and includes new sections on herpes proctitis, key points to cover with patients regarding transmission and removal of advice on the management of HSV in pregnancy which now has a separate joint BASHH/RCOG guideline.

Should men with asymptomatic non-specific urethritis be identified and treated?

There is currently a debate as to whether microscopy is necessary in asymptomatic men presenting for a sexual health screen. Arguments favouring microscopy include finding chlamydia in a significant proportion of sexual partners of men with non-specific urethritis (NSU) in studies that included symptomatic men. We aimed to investigate the proportion of partners of men with asymptomatic NSU who were diagnosed with a sexually transmitted infection. A retrospective case-note review was carried out for all men diagnosed with asymptomatic pathogen-negative NSU, and their traced sexual contacts, during a nine-month period. As a result of contact-tracing, we identified 42 partners who attended the clinic. Only one partner (2.4%) tested positive for chlamydia. A further two partners were diagnosed with a viral sexually transmitted infection (STI). The low level of chlamydia and other STIs in partners of asymptomatic men with pathogen-negative NSU does not support the routine use of microscopy to identify these patients.

Patient views on examinations as part of asymptomatic screening in sexual health clinics.

Examinations of asymptomatic patients (AP) do not always take place in sexual health clinics, partly due to the evidence that clinically significant findings (not identified by urine and blood tests) are rarely found on examination of these patients. However, it is unclear from the literature as to whether patients, given the option, would choose to be examined when fully aware of what may be identified on examination as well as the frequency of positive findings. A total of 110 men attending a sexual health clinic who self-identified as asymptomatic were given a patient information sheet (PIS) describing the place and value (if any) of examinations in AP and were asked if they would like an examination. Of the 83 truly asymptomatic men with low sexual risk involved, 86% expressed the intention of having an examination having read the PIS.

Evaluation of time for non-GU medicine physicians to diagnose HIV infection in patients presenting with HIV-related illnesses.

Some individuals with HIV in the UK are only diagnosed when they are admitted to hospitals with AIDS-defining illnesses. Early diagnosis and intervention are important to reduce the morbidity and mortality of HIV infection. Delays in diagnosing HIV infection may be expected to result in an increased risk of disease progression and complications. This retrospective cohort study was conducted between January 2002 and December 2003. Two hundred and nineteen new HIV infections were diagnosed in three hospitals in the south of England during the study period. Of these, 58 patients (35M, 23F) were diagnosed in non-GUM settings. The mean age was 39 years. Over 70% of the diagnoses were made within seven days. Eight percent of the diagnoses were made more than 50 days from the time of first presentation. The surgeons appeared no slower at diagnosing HIV infection in their patients than medical specialties. Late diagnosis of HIV infection remains a significant problem. HIV infection should be considered as part of the differential diagnoses to ensure early diagnosis and intervention.

Increasing screening frequency in men who have sex with men: impact of guidance on risk profiling on workload and earlier diagnosis of sexually transmitted infection and HIV

Summary Increasing screening frequency in men who have sex with men (MSM) engaging in high-risk behaviours can reduce prevalence of sexually transmitted infections (STIs). This evaluation investigated the impact of applying stricter screening guidelines for MSM on service workload and earlier STI diagnoses. A validated risk assessment tool (RAT) was distributed to MSM attending a level 3 sexual health service over three months. Australian screening guidelines were applied to the data to identify MSM requiring more frequent screening and data projected to the larger MSM population. The RAT identified a 2–5-fold increase in the number of STI and HIV screenings required based on six- and three-monthly screening intervals, respectively, in the MSM cohort. When screening intervals are reduced from three-monthly to six-monthly there is a potential loss of 66.7% of earlier HIV diagnoses. The use of RATs will increase workload in sexual health services, but potentially diagnose a large proportion of disease earlier.

P166 Increasing screening frequency in men who have sex with men (MSM): impact of explicit guidance on risk profiling on UK service

Background STI and HIV diagnoses are increasing among MSM. Mathematical modelling shows increasing screening frequency can reduce STI prevalence, especially targeting MSM engaging in risk behaviours. International guidelines from both the CDC and Australasian Society for HIV Medicine clearly define risk behaviours with adapted screening intervals—contrary to the UK where NICE guidance is vague. Objectives To investigate impact of applying stricter international screening guidelines for MSM, on service workload and earlier STI diagnosis in a UK level 3 service [L-3S]. Methods A validated risk questionnaire distributed to MSM attending a large provincial L-3S over a 3-month period explored their actual screening frequency, STI diagnoses and risk behaviours in the prior 12 months. Australian screening guidelines were applied to the data to identify MSM needing more frequent screening. Projections to the larger MSM population attending over 12 months were modelled, based on the demographics of the respondents. Results 126/357 completed the questionnaire, 89 were identifiable. There was no statistically significant difference between STI rates (p=0.18) and HIV diagnoses (p=0.62) between identifiable questionnaire respondents and other MSM clinic attendees. Demographic analysis showed the sample group was representative of the larger cohort. In 2011, applying Australasian Society for HIV Medicine risk profiling for the 793 MSM who attended the unit, 26% would require one additional 6-monthly attendance for HIV screening, while 6% would require two visits. Additional STI screening visits would be needed by 25% (1 visit) and 10% (2 visits). 29% of STI diagnoses were in infrequent attendees. Conclusions Stricter UK screening guidelines for MSM defining and weighting risk behaviours explicitly in line with other international guidelines, would increase L-3S MSM visits by 30% and potentially diagnose a large proportion of disease earlier. In light of the results UK guidelines may benefit from review.

Contraceptive use among women attending an open access genitourinary medicine department

Termination of pregnancy rates among young women are rising in the UK and are associated with poor use of reliable contraceptive methods. Many women attending the genitourinary (GU) department for sexually transmitted infection screening do so because of poor or no condom use and are at ongoing risk of unwanted pregnancy. Few of these women attend a contraception clinic, where a full range of contraceptive methods, including long-acting reversible contraception, are available. In this study of 152 women of reproductive age, half stated that they needed further contraceptive advice. In total four-fifths of the women without a reliable method of contraception wanted contraceptive advice and/or future contraceptive provision in the GU medicine clinic.

Inequalities in access to genitourinary medicine clinics in the UK: results from a mystery shopper survey

Study design This study investigated whether access to genitourinary medicine (GUM) clinics meets UK-recommended standards. Methods In January 2014 and 2015, postal questionnaires about appointment and service characteristics were sent to lead clinicians of UK GUM clinics. In February 2014 and 2015, researchers posing as symptomatic and asymptomatic ‘patients’ contacted clinics by telephone, requesting to be seen. Clinic and patient characteristics associated with the offer of an appointment within 48 hours were examined using unadjusted and UK country and patient gender adjusted multivariable logistic regression analyses. In March 2015, a convenience sample (one in four) of clinics was visited by researchers with the same clinical symptoms. Ability to achieve a same-day consultation and waiting time were assessed. Results In 2015, 90.8% of clinics offered symptomatic ‘patients’ an appointment within 48 hours when contacted by telephone, compared with 95.5% in 2014 (aOR=0.46 (0.26 to 0.83); p<0.01). The decline was greatest in women (96.0% to 90.1%; p<0.05), and clinics in England (96.2% to 90.7%; p<0.01). For asymptomatic patients, the proportion offered an appointment within 48 hours increased from 50.7% in 2014 to 74.5% in 2015 (aOR=3.06 (2.23 to 4.22); p<0.001), and in both men (58.2% to 90.8%; p<0.001) and women (49.0% to 59.6%; p<0.01). In adjusted analysis, asymptomatic women were significantly less likely to be offered an appointment than asymptomatic men (aOR=0.33 (0.23 to 0.45); p value<0.001). 95% of clinics were able to see symptomatic patients attending in person. Conclusions Access to GUM services has worsened for those with symptoms suggestive of an acute STI and is significantly poorer for asymptomatic women. This evidence may support the reintroduction of process targets.

O11 Using a professional patient mystery shop to evaluate management of recently diagnosed HSV-2, compared with data from a national questionnaire

Introduction In 2014, the British Association of Sexual Health and HIV updated guidelines detailing the expected management of Anogenital Herpes type 2 (HSV-2). This study aims to evaluate counselling given to patients with HSV-2 and determine how clinicians are dealing with sensitive topics that arise during these consultations. Methods 210 UK Genito-Urinary Medicine (GUM) clinics were sent an anonymous questionnaire, the results of which were analysed and compared with current guidelines. A pilot mystery shopping study, involving a patient with a reported recent HSV-2 diagnosis, was performed in 3 UK GUM Clinics. Details of each consultation were graded as A (acceptable), U (unacceptable) or C (a cause for concern) by a panel of 6 experts. Results Analysis of the returned questionnaires showed inconsistencies in answers between clinicians and guidelines. The advice given during the visits was graded 69.7% A, 16.8% C and 13.5% U. Staff performed well with providing emotional support and guiding patients to extra materials (84.5% A) but did significantly less well on topics such as disclosure (65.9% A, p=0.0025), transmission (71.8% A, p=0.032) and pregnancy (53.9% A, p=0.000013) (Pearson’s Chi-squared test). Discussion The study has exposed some short falls in clinical practice, which should be addressed by future guidelines and education events at BASHH, should they be supported by a larger-scale study. Returning anonymised data to participating clinics may allow them to deal with discrepancies in their practice.