Merle Symonds

Can we improve partner notification rates through expedited partner therapy in the UK? Findings from an exploratory trial of Accelerated Partner Therapy (APT)

Objectives To develop two new models of expedited partner therapy for the UK, and evaluate them for feasibility, acceptability and preliminary outcome estimates to inform the design of a randomised controlled trial (RCT). Methods Two models of expedited partner therapy (APTHotline and APTPharmacy), known as ‘Accelerated Partner Therapy’ (APT) were developed. A non-randomised comparative study was conducted of the two APT models and routine partner notification (PN), in which the index patient chose the PN option for his/her partner(s) in two contrasting clinics. Results The proportion of contactable partners treated when routine PN was chosen was 42/117 (36%) and was significantly higher if either APT option was chosen: APTHotline 80/135 (59%), p=0.003; APTPharmacy 29/44 (66%) p=0.001. However, partner treatment was often achieved through other routes. Although 40–60% of partners in APT groups returned urine samples for sexually transmitted infection (STI) testing, almost none accessed HIV and syphilis testing. APT options appear to facilitate faster treatment of sex partners than routine PN. Preferences and recruitment rates varied between sites, related to staff satisfaction with existing routine PN; approach to consent; and possibly, characteristics of local populations. Conclusions Both methods of APT were feasible and acceptable to many patients and led to higher rates of partner treatment than routine PN. Preferences and recruitment rates varied greatly between settings, suggesting that organisational and cultural factors may have an important impact on the feasibility of an RCT and on outcomes. Mindful of these factors, it is proposed that APT should now be evaluated in a cluster RCT.

The relative clinical effectiveness and cost-effectiveness of three contrasting approaches to partner notification for curable sexually transmitted infections: a cluster randomised trial in primary care

BACKGROUND Partner notification is the process of providing support for, informing and treating sexual partners of individuals who have been diagnosed with sexually transmitted infections (STIs). It is traditionally undertaken by specialist sexual health services, and may involve informing a partner on a patients behalf, with consent. With an increasing proportion of STIs diagnosed in general practice and other community settings, there is a growing need to understand the best way to provide partner notification for people diagnosed with a STI in this setting using a web-based referral system. OBJECTIVE We aimed to compare three different approaches to partner notification for people diagnosed with chlamydia within general practice. DESIGN Cluster randomised controlled trial. SETTING General practices in England and, within these, patients tested for and diagnosed with genital chlamydia or other bacterial STIs in that setting using a web-based referral system. INTERVENTIONS Three different approaches to partner notification: patient referral alone, or the additional offer of either provider referral or contract referral. MAIN OUTCOME MEASURES (1) Number of main partners per index patient treated for chlamydia and/or gonorrhoea/non-specific urethritis/pelvic inflammatory disease; and (2) proportion of index patients testing negative for the relevant STI at 3 months. RESULTS As testing rates for chlamydia were far lower than expected, we were unable to scale up the trial, which was concluded at pilot stage. We are not able to answer the original research question. We present the results of the work undertaken to improve recruitment to similar studies requiring opportunistic recruitment of young people in general practice. We were unable to standardise provider and contract referral separately; however, we also present results of qualitative work aimed at optimising these interventions. CONCLUSIONS External recruitment may be required to facilitate the recruitment of young people to research in general practice, especially in sensitive areas, because of specific barriers experienced by general practice staff. Costs need to be taken into account together with feasibility considerations. Partner notification interventions for bacterial STIs may not be clearly separable into the three categories of patient, provider and contract referral. Future research is needed to operationalise the approaches of provider and contract partner notification if future trials are to provide generalisable information. TRIAL REGISTRATION Current Controlled Trials ISRCTN24160819. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 5. See the NIHR Journals Library website for further project information.

Developing and testing accelerated partner therapy for partner notification for people with genital Chlamydia trachomatis diagnosed in primary care: a pilot randomised controlled trial

Background Accelerated partner therapy (APT) is a promising partner notification (PN) intervention in specialist sexual health clinic attenders. To address its applicability in primary care, we undertook a pilot randomised controlled trial (RCT) of two APT models in community settings. Methods Three-arm pilot RCT of two adjunct APT interventions: APTHotline (telephone assessment of partner(s) plus standard PN) and APTPharmacy (community pharmacist assessment of partner(s) plus routine PN), versus standard PN alone (patient referral). Index patients were women diagnosed with genital chlamydia in 12 general practices and three community contraception and sexual health (CASH) services in London and south coast of England, randomised between 1 September 2011 and 31 July 2013. Results 199 women described 339 male partners, of whom 313 were reported by the index as contactable. The proportions of contactable partners considered treated within 6 weeks of index diagnosis were APTHotline 39/111 (35%), APTPharmacy 46/100 (46%), standard patient referral 46/102 (45%). Among treated partners, 8/39 (21%) in APTHotline arm were treated via hotline and 14/46 (30%) in APTPharmacy arm were treated via pharmacy. Conclusions The two novel primary care APT models were acceptable, feasible, compliant with regulations and capable of achieving acceptable outcomes within a pilot RCT but intervention uptake was low. Although addition of these interventions to standard PN did not result in a difference between arms, overall PN uptake was higher than previously reported in similar settings, probably as a result of introducing a formal evaluation. Recruitment to an individually randomised trial proved challenging and full evaluation will likely require service-level randomisation. Trial registration number Registered UK Clinical Research Network Study Portfolio id number 10123.

P036 Improving larc uptake: a retrospective study into the role and impact of enhanced sexual health services in community pharmacies

Introduction Unwanted pregnancies and low uptake of LARC continues to be problematic in 15–44 year olds in an East London Borough. Between April 15 and March 16, 45 pharmacies were commissioned, as part of the local enhanced sexual health service (LES) to provide emergency hormonal contraception (EHC) and contraception advice with the aim of increasing LARC uptake in <25s and others at high risk of unwanted pregnancy. Pharmacies taking part in the pilot received PGD and safeguarding training and pathways into LARC were refreshed. Methods Analysis of self-sample STI tests via the Doctor’s Laboratory and consultations documented via PharmOutcomes, and corresponding search of PreView for attendances for contraceptive/LARC care during time period. Results 35/45 pharmacies (77.8%) dispensed 324 Levonorgestrel (1500 microgram) doses to women resident in the borough >13 years (average age 24.9 years; range 14.2-49.6 years). 100% of <16s had Fraser competency assessed (4). 6.2% (20/324) women had >1 attendance for EHC. 16 women (4.9%) subsequently attended local CaSH/GUM services for LARC; 8 (2.5%) for implant; 4 (1.2%) for injectable; 4 (1.2%) for IUD. Discussion Pharmacy delivered EHC and signposting to LARC services in primary and secondary care is feasible. There were limitations in the ability to gather data regarding women accessing LARC in primary care following contact with pharmacy so these numbers may under report the actual figures of those accepting LARC following pharmacy contact. Online booking systems should be accessible to pharmacists to facilitate LARC referral. Further work looking at acceptability of this strategy should be conducted.

P197 An interpretative phenomenological analysis to explore the experiences of patients after speaking with a health adviser about partner notification

Introduction Partner notification (PN) is pivotal in controlling spread of sexually transmitted infections (STI) by reducing onward transmission and preventing reinfection. We explored the experiences of patients undergoing PN after being diagnosed with a STI. Methods 259 patients diagnosed with a STI over a 3 week period were invited to complete a PN survey comprising quantitative and qualitative questions. Qualitative data was analysed using Interpretative Phenomenological Analysis (IPA). Results 76 patients, 20 female and 24 male responded (not all questions were answered). Mean age was 31 (range 16-58). 21 identified as single and 16 partnered. 29% said this was their first clinic attendance, 65% said this was their first ever STI diagnosis and 36% said they attended as a STI contact. Eight main themes were identified: (1) infection source; (2) how to contact partners; (3) difficult information to discuss ‘specific sexual acts performed with every one of them’; (4) uncertainty of partner testing and treatment; (5) concern of providing partner details; (6) future expectations; (7) use of social media; and (8) Health Adviser (HA) qualities. Patients understand PN, but face barriers due to partnership dynamics and lack the skills required for PN. Further partners were contacted following consultation with a HA. Evidence of alternative PN being offered (i.e. provider referral) was limited. Discussion In line with BASHH guidelines, the importance of specialist staff in delivering PN was evident. Novel ways to facilitate sexual history taking and methods to contact partners (i.e. social media) are preferred and should be explored further.

P201 How can sexual history taking for sexually transmitted infection partner notification be improved

Introduction National guidelines, standards and policies help health care professionals to elicit information during sexual history taking as part of partner notification (PN) for sexually transmitted infections (STI). Accurate information about sexual partners and sexual behaviours is vital to prevent onward transmission. This study focuses on patients’ experiences on how sexual history questions for the purpose of PN could be improved. Methods We conducted 12 focus groups with members of the public and patients at sexual health clinics in Glasgow and London. All patient participants had been diagnosed with a (non-HIV) STI in the past six months. Data were analysed using thematic analysis. Results Analysis revealed a number of interrelated themes arising from participants’ experiences and perceptions. Shared beliefs about sensitivity and reflexivity of questions regarding the frequency, riskiness and contactability of sexual partners influenced the way in which patients experienced and responded in sexual health consultations. Congruence in language and clinician-led consideration of the context of individual sexual behaviour contributed to the extent to which information was shared. Discussion Sexual history taking for PN is embedded within a complex interaction between clinicians and patients. The need to accurately identify all partners is balanced against acknowledging that questions asked must be sensitive yet unambiguous. This study suggests that establishing congruence in language and investing time to examine contextual factors within the patient’s sexual behaviours can lead to active collaboration within a time-efficient window, and enhancing the accuracy of information shared thereby enabling health professionals to offer appropriate options for PN.

P152 Staff satisfaction improvement work: actively asking, listening and responding to the concerns of our staff

Introduction Contract tendering and service integration has resulted in great uncertainty for sexual health staff. Our service has recently integrated with sexual and reproductive health (SRH) and is currently under tender. We aimed to review and address the satisfaction of our staff. Methods An online survey was disseminated to staff at our sexual health service. Results 73% of staff responded: 13 doctors, 9 nurses, 6 technicians, 15 health advisors/psychologists, 8 receptionists, 8 administrators, 3 anonymous. On a scale of 1–10, staff rated: feeling valued 5.9; enjoying work 6.4; day-to-day support 5.7. Scores were lower among receptionists (4, 4.1, 3.6 respectively). 61% felt day-to-day issues were dealt with in a timely manner. Cascade of information from management to staff was deemed ‘too little’ by 53%. 34% stated they did not have the opportunity to contribute to decisions affecting them. Staff found it easier to raise concerns with their line manager (6.7/10) than with management (5.7/10). These scores were lower among receptionists (3.6/10, 4/10 respectively). Discussion Improvement work is addressing the issues raised by our staff. Initiatives include: Staff Member of the Month Award; Daily team huddle actively including receptionists, addressing day-to-day issues; Psychology session with receptionists to better understand their concerns; Clinic has relocated to be next to reception (rather than on a different floor); A buddying system for incoming SRH staff; Regular integration emails from management and whole team briefings. Discussion Our survey demonstrates the need to actively ask, listen and respond to staff’s satisfaction, especially during such uncertain times.

Effectiveness and cost-effectiveness of implementing HIV testing in primary care in East London: protocol for an interrupted time series analysis.

Introduction HIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care, but evidence on implementing testing is lacking. In a previous study, the Rapid HIV Assessment 2 (RHIVA2) cluster randomised controlled trial, we showed that providing training and rapid point-of-care HIV testing at general practice registration (RHIVA2 intervention) in Hackney led to cost-effective, increased and earlier diagnosis of HIV. However, interventions effective in a trial context may be less so when implemented in routine practice. We describe the protocol for an MRC phase IV implementation programme, evaluating the impact of rolling out the RHIVA2 intervention in a post-trial setting. We will use a longitudinal study to examine if the post-trial implementation in Hackney practices is effective and cost-effective, and a cross-sectional study to compare Hackney with two adjacent boroughs providing usual primary care (Newham) and an enhanced service promoting HIV testing in primary care (Tower Hamlets). Methods and analysis Service evaluation using interrupted time series and cost-effectiveness analyses. We will include all general practices in three contiguous high HIV prevalence East London boroughs. All adults aged 16 and above registered with the practices will be included. The interventions to be examined are: a post-trial RHIVA2 implementation programme (including practice-based education and training, external quality assurance, incentive payments for rapid HIV testing and incorporation of rapid HIV testing in the sexual health Local Enhanced Service) in Hackney; the general practice sexual health Network Improved Service in Tower Hamlets and usual care in Newham. Coprimary outcomes are rates of HIV testing and new HIV diagnoses. Ethics and dissemination The chair of the Camden and Islington NHS Research Ethics Committee, London, has endorsed this programme as an evaluation of routine care. Study results will be published in peer-reviewed journals and reported to commissioners.

P215 Patient telephone consultations in a sexual health service. What do they tell us about service efficiency and patient need

Background/introduction With an ever decreasing financial envelope, sexual health services are being tasked with developing more cost effective ways of managing patients without impacting on quality of care. Centralised patient management systems have reduced the need for face to face contact, using virtual systems, based upon Health and Social Care information Centre (HSCI) definitions, to manage ongoing care for patients including partner notification. Aim(s)/objectives Analyse virtual management undertaken with patients following new attendance for episodes of STI care. To ascertain and categorise the number of virtual contacts that prevented a face to face follow up attendance. Methods Thematic analysis was performed on a randomised sample of telephone consultations definitions between 04/15 and 01/16 Results 82,994 calls were made to automated results systems. 13,373 calls were transferred from the automated system.Abstract P215 Table 1 Telephone consultations calls were analysed 2719 No follow up required 969 (35.6%) Information, support or reassurance only 640 (23.5%) Previously undiagnosed infections requiring follow up 1054 (38.8%) Initiation or verification of PN 1150 (42.9%) Referral to Level 1/2 or other services 68 (2.5%) Discussion/Conclusion The automated system manages 82% of calls without patients opting to speak with clinicians. Significant numbers of patients opted for telephone consultation upon notification of an infection, giving opportunity for initiation of PN alongside management of further testing and treatment. Approaching ¼ of consultations analysed, showed no additional testing or treatment was indicated, but advice and reassurance was the primary reason for speaking with staff. Virtual consultations can provide a high quality alternative to face to face follow-up visits.

Patient or provider referral for Chlamydia – what is the cost and is it worth it? A cost comparison of alternative strategies

Background Partner notification (PN) is an essential element of STI control. Typically partner notification has been supported by specialist health advisors based in GUM clinics, but recently the role has been extended to community based Chlamydia screening officers (including primary care). We aimed to explore and compare costs of various approaches to PN for Chlamydia in different settings. Methods We compared costs of being offered one of five approaches to partner notification from the health service perspective: Routine specialist clinic PN (patient referral including infection specific information, and advice that the sex partner should attend clinic for testing and treatment) Accelerated Partner Therapy (APT Hotline): nurse initiated PN at the general practise followed by telephone assessment of sex partner by clinic-based nurse qualified health adviser; Accelerated Partner Therapy (APT Pharmacy): nurse initiated PN at the general practise followed by assessment of sex partner by trained community pharmacist; Patient referral, where patients are advised by phone by qualified health adviser on the need for partner to be tested and treated. Provider referral, where patients accept the offer of a specialist health adviser contacting one or more partner(s) by phone. For all pathways primary costs were collected prospectively in a specific exploratory study. Results The least costly strategy is nurse led PN (strategy 2) costing approximately £53 per index case (2011 costs). The most costly strategy is provider referral (strategy 6) which cost £96 per index case. Conclusion Where health service providers assume responsibility for contacting partners there will be substantial additional cost. Before any such policy is implemented, a demonstrable improvement in PN outcomes should be established.