Gary Brook

How much do delayed healthcare seeking, delayed care provision, and diversion from primary care contribute to the transmission of STIs?

Objectives: To quantify the contribution of patient delay, provider delay, and diversion between services to delayed access to genitourinary medicine (GUM) clinics. To describe the factors associated with delay, and their contribution to STI transmission. Methods: Cross-sectional survey of 3184 consecutive new patients attending four GUM clinics purposively selected from across England to represent different types of population. Patients completed a short written questionnaire that collected data on sociodemographics, access, and health-seeking behaviour. Questionnaires were then linked to routinely collected individual-level demographic and diagnostic data. Results: Patient delay is a median of 7 days, and does not vary by demographic or social characteristics, or by clinic. However, attendance at a walk-in appointment was associated with a marked reduction in patient delay and provider delay. Among symptomatics, 44.8% of men and 58.0% of women continued to have sex while awaiting treatment, with 7.0% reporting sex with >1 partner; 4.2% of symptomatic patients reported sex without using condoms with new partner(s) since their symptoms had begun. Approximately 25% of all patients had already sought or received care in general practice, and these patients experienced greater provider delay. Conclusions: Walk-in services are associated with a reduction in patient and provider delay, and should be available to all populations. Patients attending primary care require clear care pathways when referred on to GUM clinics. Health promotion should encourage symptomatic patients to seek care quickly, and to avoid sexual contact before treatment.

The utility of short message service (SMS) texts to remind patients at higher risk of STIs and HIV to reattend for testing: a controlled before and after study

Background Patients attending for sexually transmitted infection (STI)/HIV testing may be at continuing risk of infection and advised to return for retesting at a later date. Objectives To measure the impact of short message service (SMS) text reminders on the reattendance rates of patients who require repeat STI testing. Methods Reattendance rates were measured for two groups of higher risk patients: those listed for routine SMS text reminders in 2012 and a control group of patients from 2011 with the same risk profile who had not received any active recall. Reattendance was counted if it was within 4 months of the end of the episode of care. Results Reattendance rates were not statistically different between the text group 32% (89/274) and the control group 35% (92/266). Reattendance also was not statistically different between the text and control groups respectively in patients with the following risks: recent chlamydia 43/121 (36%) versus 41/123 (33%), recent gonorrhoea 4/21 (19%) versus 7/21 (33%), recent emergency contraception 27/60 (45%) versus 25/56 (45%) and other risks 7/27 (26%) versus 9/26 (35%). High rates of STIs were found in patients who reattended in both the text group (13/90, 14%) and control group (15/91, 17%) and at even higher rates at reattendance if the reason for recall was chlamydia infection at the initial visit: 9/43 (21%) in the text group and 10/41 (24%) in the control group. Conclusions SMS texts sent as reminders to patients at higher risk of STIs and HIV did not increase the reattendance rate, when compared with standard advice, in this service which already has a high reattendance rate. STI rates were high in those patients who reattended.

Testing for sexually transmitted infections in general practice: cross-sectional study

BackgroundPrimary care is an important provider of sexual health care in England. We sought to explore the extent of testing for chlamydia and HIV in general practice and its relation to associated measures of sexual health in two contrasting geographical settings.MethodsWe analysed chlamydia and HIV testing data from 64 general practices and one genitourinary medicine (GUM) clinic in Brent (from mid-2003 to mid-2006) and 143 general practices and two GUM clinics in Avon (2004). We examined associations between practice testing status, practice characteristics and hypothesised markers of population need (area level teenage conception rates and Index of Multiple Deprivation, IMD scores).ResultsNo HIV or chlamydia testing was done in 19% (12/64) of general practices in Brent, compared to 2.1% (3/143) in Avon. In Brent, the mean age of general practitioners (GPs) in Brent practices that tested for chlamydia or HIV was lower than in those that had not conducted testing. Practices where no HIV testing was done had slightly higher local teenage conception rates (median 23.5 vs. 17.4/1000 women aged 15-44, p = 0.07) and served more deprived areas (median IMD score 27.1 vs. 21.8, p = 0.05). Mean yearly chlamydia and HIV testing rates, in practices that did test were 33.2 and 0.6 (per 1000 patients aged 15-44 years) in Brent, and 34.1 and 10.3 in Avon, respectively. In Brent practices only 20% of chlamydia tests were conducted in patients aged under 25 years, compared with 39% in Avon.ConclusionsThere are substantial geographical differences in the intensity of chlamydia and HIV testing in general practice. Interventions to facilitate sexually transmitted infection and HIV testing in general practice are needed to improve access to effective sexual health care. The use of routinely-collected laboratory, practice-level and demographic data for monitoring sexual health service provision and informing service planning should be more widely evaluated.

Disclosure of anogenital warts to sexual partners

Objectives: To investigate psychological functioning, relationship factors, stigma perception, disclosure outcomes and regret about the disclosure decision in people being treated for anogenital warts, comparing disclosers and non-disclosers and evaluating the possible predictors of disclosure. Method: A self-completion questionnaire was completed by 54 participants recruited from a London genitourinary medicine clinic. There were 36 disclosers and 18 non-disclosers. Results: Disclosers were significantly less anxious than non-disclosers (p<0.01). Compared with non-disclosers, disclosers also rated their relationships as longer lasting (p<0.001) and closer (p<0.01). Disclosers were less likely to express regret about their disclosure decision than were non-disclosers (p<0.001). There were no significant differences between groups with regard to depression, self-esteem, expected partner response to disclosure, or sexually transmitted infection (STI)-related stigma perception, although there was a trend towards higher stigma perception in disclosers (p = 0.15). The actual partner response to disclosure was significantly more supportive than had been expected (p<0.001). A binary logistic regression model used three variables to predict disclosure status with an accuracy of 83%. Disclosers were predicted by lower anxiety levels, longer relationship duration and higher stigma perception. Conclusions: Relationship factors, in particular duration, were key predictors of partner disclosure of anogenital warts. In terms of individual characteristics, only anxiety was significantly different in disclosers and non-disclosers. Perceptions of stigma and expected outcome of disclosure were not significantly different in the two groups. Of particular relevance to those considering whether or not to disclose, partner response was significantly more supportive than disclosers expected and disclosers expressed significantly less regret about their disclosure decision than did non-disclosers.

Sexually transmitted infection risk exposure among black and minority ethnic youth in northwest London: findings from a study translating a sexually transmitted infection risk-reduction intervention to the UK setting

Objectives: Young black women are disproportionately affected by sexually transmitted infections (STI) in the UK, but effective interventions to address this are lacking. The Young Brent Project explored the nature and context of sexual risk-taking in young people to inform the translation of an effective clinic-based STI reduction intervention (Project SAFE) from the USA to the UK. Methods: One-to-one in-depth interviews (n  =  37) and group discussions (n  =  10) were conducted among men and women aged 15–27 years from different ethnic backgrounds recruited from youth and genitourinary medicine clinic settings in Brent, London. The interviews explored the context within which STI-related risks were assessed, experienced and avoided, the skills needed to recognise risk and the barriers to behaviour change. Results: Concurrent sexual partnerships, mismatched perceptions and expectations, and barriers to condom use contributed to STI risk exposure and difficulties in implementing risk-reduction strategies. Women attempted to achieve monogamy, but experienced complex and fluid sexual relationships. Low risk awareness, flawed partner risk assessments, negative perceptions of condoms and lack of control hindered condom use. Whereas men made conscious decisions, women experienced persuasion, deceit and difficulty in requesting condom use, particularly with older partners. Conclusions: Knowledge of STI and condom use skills is not enough to equip young people with the means to reduce STI risk. Interventions with young women need to place greater emphasis on: entering and maintaining healthy relationships; awareness of risks attached to different forms of concurrency and how concurrency arises; skills to redress power imbalances and building self-esteem.

Building the bypass—implications of improved access to sexual healthcare: evidence from surveys of patients attending contrasting genitourinary medicine clinics across England in 2004/2005 and 2009

Objective The objective of this study was to examine changes in patient routes into genitourinary medicine (GUM) clinics since policy changes in England sought to improve access to sexual healthcare. Methods Cross-sectional patient surveys at contrasting GUM clinics in England in 2004/2005 (seven clinics, 4600 patients) and 2009 (four clinics, 1504 patients). Patients completed a short pen-and-paper questionnaire that was then linked to an extract of their clinical data. Results Symptoms remained the most common reason patients cited for attending GUM (46% in both surveys), yet the proportion of patients having sexually transmitted infection (STI) diagnosis/es declined between 2004/2005 and 2009: 38%–29% of men and 28%–17% of women. Patients in 2009 waited less time before seeking care: median 7 days (2004/2005) versus 3 days (2009), in line with shorter GUM waiting times (median 7 vs 0 days, respectively). Fewer GUM patients in 2009 first sought care elsewhere (23% vs 39% in 2004/2005), largely from general practice, extending their time to attending GUM by a median of 2 days in 2009 (vs 5 days in 2004/2005). Patients with symptoms in 2009 were less likely than patients in 2004/2005 to report sex since recognising a need to seek care, but this was still reported by 25% of men and 38% of women (vs 44% and 58%, respectively, in 2004/2005). Conclusions Patient routes to GUM shortened between 2004/2005 and 2009. While GUM patients in 2009 were less likely overall to have STIs diagnosed, perhaps reflecting lower risk behaviour, there remains a substantial proportion of high-risk individuals requiring comprehensive care. Behavioural surveillance across all STI services is therefore essential to monitor and maximise their public health impact.

How and why do South Asians attend GUM clinics? Evidence from contrasting GUM clinics across England.

Background Improving access to sexual healthcare is a priority in the UK, especially for ethnic minorities. Though South Asians in the UK report low levels of sexual ill health, few data exist regarding their use of genitourinary medicine (GUM) services. Objectives To describe reasons for attendance at GUM clinics among individuals of South Asian origin relative to patients of other ethnicities. Methods 4600 new attendees (5% South Asian; n=226) at seven sociodemographically and geographically contrasting GUM clinics across England completed a questionnaire between October 2004 and March 2005, which were linked to routine clinical data. Results South Asians were more likely than other groups to be signposted to the GUM clinic by another health service—for example, in women 14% versus 8% respectively (p=0.005) reported doing so from a family planning clinic. These women also reported that they would be less likely to go to the clinic if their symptoms resolved spontaneously compared with other women (51% vs 31%, p=0.024). However, relative to other clinic attendees, no differences in the proportions of South Asians who had acute STI(s) diagnosed at clinic were noted. Furthermore, South Asian men were more likely to report as their reason for attendance that they wanted an HIV test (23.4% vs 14.8%, p=0.005). Conclusion Despite having similar STI care needs to attendees from other ethnic groups, South Asians, especially women, may be reluctant to seek care from GUM clinics, especially if their symptoms resolve. Sexual health services need to develop locally-delivered and culturally-appropriate initiatives to improve care pathways.

Primary care consultations and costs among HIV-positive individuals in UK primary care 1995–2005: a cohort study

Objectives: To investigate the role of primary care in the management of HIV and estimate primary care-associated costs at a time of rising prevalence. Methods: Retrospective cohort study between 1995 and 2005, using data from general practices contributing data to the UK General Practice Research Database. Patterns of consultation and morbidity and associated consultation costs were analysed among all practice-registered patients for whom HIV-positive status was recorded in the general practice record. Results: 348 practices yielded 5504 person-years (py) of follow-up for known HIV-positive patients, who consult in general practice frequently (4.2 consultations/py by men, 5.2 consultations/py by women, in 2005) for a range of conditions. Consultation rates declined in the late 1990s from 5.0 and 7.3 consultations/py in 1995 in men and women, respectively, converging to rates similar to the wider population. Costs of consultation (general practitioner and nurse, combined) reflect these changes, at £100.27 for male patients and £117.08 for female patients in 2005. Approximately one in six medications prescribed in primary care for HIV-positive individuals has the potential for major interaction with antiretroviral medications. Conclusion: HIV-positive individuals known in general practice now consult on a similar scale to the wider population. Further research should be undertaken to explore how primary care can best contribute to improving the health outcomes of this group with chronic illness. Their substantial use of primary care suggests there may be potential to develop effective integrated care pathways.

The importance of distinguishing between black Caribbeans and Africans in understanding sexual risk and care-seeking behaviours for sexually transmitted infections: evidence from a large survey of people attending genitourinary medicine clinics in England

BACKGROUND In the UK, black Caribbean and African populations experience disproportionately high rates of sexually transmitted infections (STIs) and HIV. Often studies do not differentiate between these populations notwithstanding differences in STI epidemiology and sociodemographics. METHODS Patterns of care-seeking behaviour for STIs were explored separately for black Caribbean (n = 345), black African (n = 193) and white people through a cross-sectional survey of 2824 people attending five genitourinary medicine (GUM) clinics in England. RESULTS Black Caribbean men were least likely to use, or try to use, their general practice surgery prior to GUM clinic attendance (16.6%). Symptomatic black Caribbean and African men were least likely to delay seeking care (30.8 and 26.3%, respectively). Symptomatic black Caribbean men faced the least provider delay in accessing care (27.3%). Black Caribbean men and women were most likely, and black African men and women least likely, to be diagnosed with an STI (49.7 and 32.0% versus 26.8 and 16.3%, respectively). Among symptomatic women, black Caribbeans and, among symptomatic men, black Africans were most likely to report abstaining from sex (46.3 and 73.1%, respectively). CONCLUSIONS Our analyses highlight the importance of distinguishing between black ethnic groups and the need for future studies to ensure sufficiently large samples to permit such analyses.

The limits of health-care seeking behaviour: how long will patients travel for STI care? Evidence from England's ‘Patient Access and the Transmission of Sexually Transmitted Infections’ (‘PATSI’) study

The objective of this study was to identify factors associated with (i) longer patient travel time to genitourinary (GU) medicine clinics and (ii) not attending the nearest clinic. Questionnaires were completed by 4600 new attendees from seven sociodemographically and geographically different GU clinics across England between October 2004 and March 2005. These data were then linked to the routine clinic database. Median travel time was 25 minutes and varied significantly by clinic (P < 0.001) but not by gender (P = 0.96). Of all the respondents, 10% spent at least one hour getting to a GU clinic and this was significantly more likely in patients with less education, those who travelled by public transport and those who did not attend their closest clinic. Longer travel times were not associated with delays in seeking care. Patients reporting a previous sexually transmitted infection (STI) diagnosis were more likely not to go to their nearest GU clinic (P = 0.0006), as were those who used/tried to use other healthcare providers prior to attending the clinic (P = 0.007). To facilitate access to STI care, comprehensive local services need to be provided to avoid long journey times, especially for those who have to rely on public transport to get to clinic.