Mark FitzGerald

The outcome of contact tracing for gonorrhoea in the United Kingdom

Tracing and treating contacts (partner notification, PN) is a crucial part of the control of sexually transmitted infections but few studies have quantified its outcome. A retrospective national study obtained information from 155 clinics on 1308 patients with gonorrhoea, 59% of all UK patients attending in January to March 1995. These gave 1887 contacts (1 : 1.5) of whom 621 attended, 75% being found to be infected. The ratio of contacts attending to index patients was 0.5 (621/ 1260). The ratio was not influenced by gender or ethnicity, but was affected by orientation, being 0.5 for contacts of male heterosexuals, 0.3 for contacts of male < homosexuals (P 0.001). PN outcome was less good in metropolitan (0.3) than provincial clinics (0.5), suggesting that further research is necessary on the reasons for this difference. Reliable ongoing outcome audit will require good communication between clinics to verify that contacts have attended. The contact:index ratio is suitable for evaluation of PN as it relates to actual outcome rather than to the patients account of contact numbers. Local work can be assessed against these national figures.

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.

British Association for Sexual Health and HIV: framework for guideline development and assessment.

Summary The Clinical Effectiveness Group of the British Association for Sexual Health has updated their methodology for the production of national guidelines for the management of sexually transmitted infections and related conditions. The main changes are the adoption of the GRADE system for assessing evidence and making recommendations and the introduction of a specific Conflict of Interests policy for Clinical Effectiveness Group members and guideline authors. This new methodology has been piloted during the production of the 2015 British Association for Sexual Health & HIV guideline on the management of syphilis.

Measuring the effectiveness of contact tracing

Contact tracing or partner noti® cation has as its major objectives: to contribute to the control of sexually transmitted diseases (STDs) in the population; to identify previously unrecognized cases of infection and through treatment to prevent the development of serious sequelae; and to improve patient management by reducing repeat infections1. Its historical background, role and methods have recently been reviewed2 emphasizing that contact tracing can be most strongly justi® ed in the management of bacterial STDs, where curative treatment is available. The strategies used, personnel involved and methods have been the subject of a large number of studies which were reviewed by Oxman and colleagues3 with the conclusion that there is only weak evidence for the effectiveness of the interventions currently undertaken. Furthermore, even if an intervention is shown to be effective in one setting, it may be unacceptable or ineffective in another population, or not appropriate to the requirements of the day. For example, in Newcastle in 1946 the majority of contact tracing was by provider activity, but this became progressively less appropriate and by 1970 was mainly by patient referral4. All this leaves health advisers (the individuals mostly responsible for partner noti® cation in the UK) with a practical dilemma. They may be practising in a way which seems acceptable to the patients they see and likely to obtain their cooperation, but without a scienti® c evidence base to support their practice, or even to characterize the suitability of their patient population for one intervention rather than another, they cannot provide ® rm justi® cation for what they do. In times of ® nancial stringency, they are potentially the most vulnerable part of the STD control team. The most signi® cant measure for a control strategy must be the prevalence of the STD in the population, but in practice this is very dif® cult to monitor. Herpes simplex serology, which can now differentiate type I and type II infections, provides an index of population prevalence, but as it remains positive inde® nitely the effect of any interventions on behaviour change will not be detectable for many years5. For bacterial STDs, prevalence testing has so far proved impracticable and even with the advent of non-invasive sampling it is likely always to be very costly in effort. The incidence of the complications of gonorrhoea or chlamydia, tubal infertility or acute pelvic in ̄ ammatory disease, is an outcome measure that could be collected systematically, but diagnosed episodes will under-represent the true incidence of events. Even where these measures have been used to show an improvement in control of an STD, as with chlamydia in Sweden6 they can only indicate the end results of many factors including access to treatment, public education, and secular changes in behaviour. Hence a narrower focus on a measurable aspect of contact tracing is necessary. A number of measures have been proposed, some of which have been used in previously reported work (Table 1). The number of partners who attend the clinic in response to partner noti® cation (contact tracing, PN) is a measure that intuitively seems signi® cant, and has been used in the paper presented on pages 657± 660 of this issue. It requires information about partners attending to be fed back to the site where the index diagnosis was made, so is particularly useful in settings where there is a uni® ed STD service with good communications between providers, International Journal of STD & AIDS 1998; 9: 645± 646

Developing sexually transmitted disease guidelines in the USA and the UK

Management guidelines for sexually transmitted diseases are reviewed and updated every four years at a workshop of experts convened by the US Centers for Disease Control and Prevention. They are disseminated in paper and electronic formats, and are widely accessed. Their recommendations are graded according to quality of evidence, benefits versus harms, and applicability. In the UK, guidelines are commissioned by the Clinical Effectiveness Group, following a specific methodology, then modified after consultation within the specialty of genitourinary medicine. Some issues are problematic for both guidelines, notably areas where the evidence is weak, where diagnostics and treatments are changing rapidly, and in knowing the extent to which guidelines actually influence practice.

Why we like clinical guidelines

“What are the best things about BASHH (British Association for Sexual Health and HIV)?” was a question posed in the strategy consultation held in August 2011. Patient care and clinical governance was seen as an ‘extremely high’ priority for BASHH by almost everyone responding, and the ‘best thing’ chosen by 96% of the 258 members participating were the clinical guidelines (J Wilson, personal communication). These were given as the main reasons for using the BASHH website by 98% of those responding, and were said to be ‘completely’ or ‘mostly’ relevant to their clinical practice. The usage figures for the website substantiate this, with the guidelines receiving nearly 100 000 hits each year,1 a dramatic growth since the first national guideline (gonorrhoea) was published in 1996. At …