Raj Patel

Destigmatising STIs: remaining challenges, new opportunities

The potential barriers to attendance at specialist sexually transmitted infection (STI) services have long been recognised. The Royal Commission report in 1916 advised that to be effective, services needed to be “skilled, free … and provided at the earliest possible moment.” In addition, clinicians needed to be aware of “the fear of disgrace and the consequent desire for concealment” that could hamper treatment delivery.1 In many respects the UK GUM services have risen to these challenges. The majority of clinics provide timely, effective care from easy to access and well located clinics.2 We are successful at attracting new referrals and have seen a year on year increase in voluntary attendances with a record 1.5 million consultations in 1999. With this level of success it would be easy to conclude that STI services are both accessible and acceptable for at least the majority of the UK population. However, it would appear that many patients with known or suspected STIs are still reluctant to attend genitourinary medicine (GUM) clinics for care. The principal suspected reason for this is the stigma associated with an STI diagnosis, which may be reinforced by the need for attendance at GUM clinics.3 In this regard, genitourinary medicine has much in common with mental health and cancer services. However, GUM specialists particularly value open access and strive to provide a confidential, non-judgmental, and supportive service, so it is particularly galling for them that …

'The waiting game': are current chlamydia and gonorrhoea near-patient/point-of-care tests acceptable to service users and will they impact on treatment?

The objective of this study was to assess the length of time service users were prepared to wait for chlamydia and gonorrhoea (CT/GC) near-patient/point-of-care test (NP-POCT) results and to determine the possible effect on management. Individuals attending two UK clinics from November 2013 to February 2014 were surveyed asking the maximum length of time they would wait for CT/GC NP-POCT results after consultation. Linked CT/GC prevalence and treatment rates were analysed. A total of 1817 participants were surveyed, and 1356 provided CT/GC NAAT samples, in which it was found that 115 (8.5%) could wait over 90u2009minutes in clinic for their result. 115 received treatment at consultation, of which 50 were CT/GC negative and 12 were treated for urethritis or cervicitis; 38 attended as CT/GC contacts. Six of this population would have waited over 90u2009minutes were NP-POCTs available. A total of 129 tested CT/GC positive, of whom 65 were treated at their consultation, 61 at a later date, and three were untreated. Twelve of these 129 patients would also have waited over 90u2009minutes for a NP-POCT result. We conclude that 90-minute NP-POCTs are not acceptable to most clinic attendees and would not have impacted on treatment rates or inappropriate prescribing, and 20-minute NP-POCTs show a marginal benefit in treating CT/GC. While NP-POCTs for CT/GC are promising, they must meet client expectations and enhance disease management in order to be accepted by patients and clinicians.

Advising patients with genital herpes.

The traditional view of genital herpes is that it is a low prevalence sexually transmitted disease, principally caused by herpes simplex virus type 2.1 However, the new type specific antibody tests, which can accurately distinguish between antibodies to herpes simplex virus type 1 and type 2, have shown that infection with herpes simplex virus type 2 is not only common2 3 4 but often goes unrecognised–only about a third of those infected are diagnosed.3 5 Among patients in Britain presenting with a first episode of genital herpes, infection due to herpes simplex virus type 1 is common, accounting for 20-60% of cases.6 7 8nnGenital herpes is often associated with considerable psychosexual morbidity, particularly around the time of initial diagnosis.9 A major concern for infected people is that they may infect their sexual partners.10 In the past, patients were reassured that this could happen only if they had sex during episodes of acute genital blistering and ulceration.11 12 Recent data from epidemiological, natural course, and antiviral studies suggest that this advice may be misleading. In one of the few prospective studies of transmission of genital herpes, …

Can an asymptomatic screening pathway for men-who-have sex-with-men be introduced safely at a level 3 sexual health service in the UK?

Summary To manage the rising demand on sexual health services in the UK, many clinics have introduced asymptomatic screening pathways for heterosexuals, which omit examination. In men who have sex with men however the screening of extragenital sites poses additional challenges. This study aimed to establish whether omitting examination of asymptomatic men who have sex with men would lead to clinically significant diagnoses being missed. The notes of all men who have sex with men who attended a UK level 3 sexual health clinic between 1 July 2011 and 30 June 2012 were retrospectively reviewed. Exclusion criteria included HIV-positive patients attending for HIV-related care, attendances for follow-up consultations not requiring a full sexual health screen, symptomatic patients, contacts of sexually transmitted infections and patients requesting an examination or a repeat prescription of a regularly used medication. In all, 920 consultations occurred during 12 months, of which 893 were reviewed; 476 (53.3%) consultations would have been eligible for screening on an asymptomatic pathway and, of these, 21 (4.4%) had abnormalities found at examination. Findings included genital warts, minor dermatological conditions and three cases of minor asymptomatic urological conditions. There were no clinically significant findings on examination of asymptomatic men who have sex with men requiring treatment, indicating that examination in this cohort may be of little benefit.

P124 Confidentiality in sexual health clinics: A service evaluation of patients’ understandings and attitudes to additional confidentiality protections

Background/introduction UK sexual health clinics provide patients with additional confidentiality by having separate patient records systems, and by not routinely communicating with General Practitioners (GPs). However, research into patients’ awareness of these policies is limited. Aim(s)/objectives To assess patients’ knowledge and perceptions of additional confidentiality protections in sexual health clinics. Methods A self-administered anonymous questionnaire (approved by Trust Clinical Governance Committee) was distributed prospectively to 200 patients attending two level 3 UK sexual health clinics. Results Response rate was 178/200 (89.0%). 46/178 (25.8%) patients were aware that sexual health records are kept separately from other medical records, and 89/178 (50.0%) had never been told how their notes are handled. After learning more about confidentiality protections in sexual health clinics, 47/178 (26.4%) reported that they would be more likely to give GP details, 67/178 (37.6%) to give updated contact details, and 58/178 (32.6%) to disclose an accurate sexual history to clinicians. Patients were less confident that their information is kept confidential in the reception area compared to the treatment area (46.9% vs 77.3% feel definitely confident). 16/17 free-text comments received complained about personal information being overheard when registering at the reception. Discussion/conclusion Sexual health clinics should ensure they provide basic information on additional confidentiality protections, in order to increase the likelihood of patients disclosing intimate information, and ensuring they can be contacted. Efforts to improve patients’ perception of confidentiality in reception areas are vital and need to be considered carefully when designing units.

P115 Is genital herpes simplex virus type 1 (HSV-1) associated with high risk sexual behaviours?

Background/introduction HSV-1 is the primary cause of genital herpes in the UK. Genital HSV has been linked with early sexual debut as well as men-who-have-sex-with-men (MSM), but previous studies do not differentiate between genital HSV-1 and HSV-2. A diagnosis of genital herpes is often distressing to patients due to stigma surrounding herpes, and receiving a sexually transmitted infection (STI) diagnosis. Aim(s)/objectives To assess whether genital HSV-1 is associated with high risk sexual behaviours in comparison with HSV-2, chlamydia, or asymptomatic patients with no STI diagnosis. Methods An NRES approved questionnaire assessing sexual behaviour - based on NATSAL questions and other recognised risk taking behaviours - was completed by 125 patients attending a UK level 3 sexual health service, with a diagnosis of first episode genital HSV-1 or HSV-2, or a diagnosis of chlamydia or asymptomatic with no STI diagnosis. Results Preliminary results show that the chlamydia group is the highest risk takers; in comparison, the HSV-1 group have lower risk sexual histories.Abstract P115 Table 1 HSV and sexual behaviour Age at first vaginal sex (years) Condom usage (%) Condom usage at most recent vaginal sex (%) Age at first receptive oral sex (years) Age at giving first oral sex (years) Number of new partners in the last year HSV-1 (10) 16.8 75 37.5 17.5 17.1 1.8 HSV-2 (15) 16.1 66.7 38.1 16.5 16.5 2.7 Chlamydia (50) 16 67.4 22.5 16.8 16.8 4.2 Asymptomatic (50) 17 60.4 33.3 16.7 17 2.6 Discussion/conclusion Provisional results have shown that HSV-1 genital herpes may not be associated with high risk sexual behaviour. In order to challenge the stigma surrounding genital herpes, further research is required.