Keith Radcliffe

2015 UK National Guideline on the management of non-gonococcal urethritis

We present the updated British Association for Sexual Health and HIV guideline for the management of non-gonococcal urethritis in men. This document includes a review of the current literature on its aetiology, diagnosis and management. In particular it highlights the emerging evidence that azithromycin 1 g may result in the development of antimicrobial resistance in Mycoplasma genitalium and that neither azithromycin 1 g nor doxycycline 100 mg twice daily for seven days achieves a cure rate of >90% for this micro-organism. Evidence-based diagnostic and management strategies for men presenting with symptoms suggestive of urethritis, those confirmed to have non-gonococcal urethritis and those with persistent symptoms following first-line treatment are detailed.

The performance and clinical utility of cervical microscopy for the diagnosis of gonorrhoea in women in the era of the NAAT

We evaluated the performance and clinical utility of cervical microscopy for diagnosing genital gonorrhoea (GC) in women, using the APTIMA Combo 2 dual GC/Chlamydia trachomatis assay as the gold standard. Test performance was assessed overall and for patient subgroups (symptomatic, GC contacts, pelvic inflammatory disease [PID] diagnosis). It was found that 93 women had positive GC genital NAAT results; 15 had positive cervical microscopy (8 were GC contacts). In all subgroups except GC contacts, the PPV of cervical microscopy was below the nationally accepted target of 90%. Compared to APTIMA Combo 2, cervical microscopy has poor sensitivity for diagnosing GC in women (16.1% overall, 17.3% symptomatic, 25% GC contacts, 10.5% PID). GC contacts accounted for over 50% of the positive microscopy results and would have received epidemiological treatment for GC, regardless of the microscopy result. Discontinuing the routine use of cervical microscopy would improve patient flow through the sexual health clinic and resources could be utilised more effectively.

Screening for hazardous alcohol consumption in a sexual health clinic: a service evaluation

On the basis of National Institute for Health and Clinical Excellence (NICE) guidance we conducted a survey in a sexual health clinic to assess acceptability of an alcohol screening questionnaire, rates of hazardous drinking and success of referral to a specialist alcohol service (Aquarius). Seventy-two percent of patients accepted the offer of screening, of whom 34% were hazardous drinkers; 2.6% consented to referral to Aquarius but failed to attend. We estimate the cost range to screen and deliver a five-minute brief intervention at £3.62–£9.19 per case. Opportunistic alcohol screening identifies high rates of hazardous drinkers and is acceptable to patients, but onward referral by untrained staff to an external specialist alcohol service is unsatisfactory to patients. Research into the cost-effectiveness of screening and delivery of brief interventions within sexual health clinics is required.

Do attendees at sexual health and HIV clinics prefer to be called in by name or number

Calling patients in from the waiting area is an important aspect of the initial medical encounter. According to national and international guidelines, clinics should decide on an appropriate way of calling patients in from the waiting room for consultations; however, no preference is actually recommended. A survey was carried out to see if patients were happy to be called in by number, first name, surname, full name, or title (Mr/Mrs/Miss/Ms) followed by surname. One hundred unselected patients were drawn from each clinic including; a genito-urinary medicine (GUM), a co-located GUM (cGUM) and co-located reproductive health (cRH), an HIV and a reproductive health (RH) clinic. Patients from the GUM, cGUM, cRH and RH clinics preferred to be called in by number rather than full name or title. Patients from the cRH clinic also preferred number to first name. In contrast, patients from the HIV clinics preferred to be called in by first name rather than number, surname, full name or title. Following this survey it would appear that number would be the most popular method of calling patients in sexual and reproductive health clinics and first name is the choice in HIV clinics.

Highlighting the clinical need for diagnosing Mycoplasma genitalium infection

Despite Mycoplasma genitalium (MG) being increasingly recognised as a genital pathogen in men and women, awareness and utility of commercially available MG-testing has been low. The opinion of UK sexual health clinicians and allied professionals was sought on how MG-testing should be used. Thirty-two consensus statements were developed by an expert group and circulated to clinicians and laboratory staff, who were asked to evaluate their level of agreement with each statement; 75% agreement was set as the threshold for defining consensus for each statement. A modified Delphi approach was used and high levels of agreement obviated the need to test the original statement set further. Of 201 individuals who received questionnaires, 60 responded, most (48) being sexual health consultants, more than 10% of the total in the UK. Twenty-seven (84.4%) of the statements exceeded the 75% threshold. Respondents strongly supported MG-testing of patients with urethritis, pelvic inflammatory disease or unexplained persistent vaginal discharge, or post-coital bleeding. Fewer favoured testing patients with proctitis and support was divided for routinely testing Chlamydia-positive patients. Testing of current sexual contacts of MG-positive patients was supported, as was a test of cure for MG-positive patients, although agreement fell below the 75% threshold. Respondents agreed that all consultant- or specialist-led services should have access to testing for MG (98.3%). There was strong agreement for having MG-testing available for specific patient groups, which may reflect concern over antibiotic resistance and the desire to comply with clinical guidelines that recommend MG-testing in sexual health clinic settings.

The management of isolated positive syphilis enzyme immunoassay results in HIV-negative patients attending a sexual health clinic.

An unconfirmed positive treponemal enzyme immunoassay (enzyme immunoassay positive, Treponema pallidum particle agglutination negative and rapid plasma reagin negative) presents a clinical challenge to distinguish early syphilis infection from false-positive results. These cases are referred for syphilis line assay (INNO-LIA) and recalled for repeat syphilis serology. We performed a retrospective audit to establish the proportion of HIV-negative cases with unconfirmed positive enzyme immunoassay results, the proportion of these cases that received an INNO-LIA test and repeat syphilis serology testing and reviewed the clinical outcomes; 0.35% (80/22687) cases had an unconfirmed positive treponemal enzyme immunoassay result. Repeat syphilis serology was performed in 80% (64/80) cases, but no additional cases of syphilis were identified. Eighty-eight per cent (70/80) received an INNO-LIA test; 14% (5/37) unconfirmed enzyme immunoassay-positive cases with no prior history of syphilis were confirmed on INNO-LIA assay, supporting a diagnosis of latent syphilis. As a confirmatory treponemal test, the INNO-LIA assay may be more useful than repeat syphilis serological testing.

Screening for alcohol use disorders in a genitourinary medicine and contraception clinic: a service evaluation

Summary National Institute for Health and Clinical Excellence guidance advises that all patients routinely undergo alcohol screening. Our service evaluation in a sexual health clinic assessed the acceptability of alcohol screening, the prevalence of hazardous drinking and the uptake of referral to a specialist alcohol service. Three services were evaluated: a genitourinary medicine service, a contraception service and an integrated sexual health service. AUDIT was used to screen 276 patients; those scoring ≥8 were classified as hazardous drinkers. Screening uptake was 58% overall, 58% for the contraception service, 71% for the genitourinary medicine service and 100% for the integrated sexual health service. Overall, 28% had AUDIT scores ≥8. Hazardous drinking rates were higher in the genitourinary medicine (32%) and integrated sexual health services (52%) compared to the contraception service (21%); 7% of hazardous drinkers accepted referral. High rates of hazardous drinking were identified within all three groups, but uptake of referral was low. Alternative strategies to specialist alcohol service referral are discussed.

Sexual health? Public health!

Reforms in the National Health Service (NHS) in England have given those of us working in the national network of genitourinary medicine (GUM) clinics reason to reflect on their role. The conclusion that the UK national specialty society (BASHH, British Association for Sexual Health and HIV) has come to is that GUM clinics are important because their core functions of testing for, and managing cases of, sexually transmitted infections (STI) including HIV, make an important contribution to the public health. Professor Sir Donald Acheson, the UKs Chief Medical Officer between 1983 and 1991, defined public health as: ‘The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’. In this editorial I shall summarise the ways in which GUM clinics contribute to these goals. First, through prevention of HIV infection. This is of major importance both because delayed diagnosis is a cause of morbidity and mortality which is avoidable with antiretroviral therapy but also because of the enormous costs to the NHS and other pubic services. Each case will cost the NHS approximately £12 000 a year for treatment indefinitely given the long life expectancy of HIV-infected persons. It has been projected that by 2013 the annual cost will be £1 billion.1 GUM clinics contribute to reducing transmission of HIV in several ways: first by diagnosing people as HIV-infected which has been shown in two meta-analyses to result in a very significant reduction in unsafe sexual behaviour.2 …

Relation between information and advice provision to male GUM clinic attendees and sexual orientation and ethnic group.

Objectives: To examine whether the provision of advice and information to male genitourinary medicine (GUM) clinic attendees was related to their reasons for attendance, ethnicity, or sexual orientation. Method: Cross sectional survey of men attending a large city centre GUM clinic. Data were collected using an anonymous subject completed questionnaire. Results: Of the 302 men recruited, 72% described themselves as white and 85% reported only female sexual partners. Information and advice provision were generally found to reflect reason for attendance—for example, those attending with a concern about “an STD or urinary problem” were more likely to report advice and information on NSU/chlamydia, herpes, gonorrhoea, or syphilis than those attending without such concerns. For those attending with a concern about HIV less than half (42%) reported receiving advice and information about HIV. The reasons for attendance were found to vary with ethnicity (black men were more likely to attend for a “check up,” and less likely to attend about HIV or with genital warts than white men) and sexual orientation (those with male partners were more likely to attend about HIV or hepatitis B than those with only female partners); there were corresponding variations in the provision of advice and information. Conclusions: The clinic was generally providing advice and information appropriate to the reasons for attendance and this reflected variations in such needs with ethnicity and sexual orientation. The provision of advice and information about HIV could be more comprehensive.