The last eighteen months has brought numerous issues in sexual health into the public eye in the United Kingdom. Influential publications during this period have included guidelines on testing for HIV, the Department of Health’s review of the national strategy for sexual health and HIV and reviewed NICE guidelines for antenatal care. We have also seen the national roll-out of the national Chlamydia Screening Programme. Other developments such as Best Practice in Testing and Treatment for STIs in women have evolved more gradually but may not be accessible to those not working directly in sexual health. This article will attempt to cover all these issues in enough measure to guide basic practice, with guidance on where further information may be sought.
Sexual health in the United Kingdom was reviewed in the Department of Health (DOH) document on the national strategy for Sexual Health and HIV, published in July 2008.
- 14% of people said they would never or rarely, use a condom with a new sexual partner;
- Numbers of new STI diagnoses at GUM clinics have risen steadily over the last 10 years. The highest rates are in young people and men who have sex with men;
- 16-24 year-olds account for nearly half of all STIs diagnosed in GUM clinics;
- 9.5% of women and 8.4% of men aged under 25, test positive for Chlamydia when screened;
- Afro-Caribbeans continue to have a very high incidence of STIs, accounting for 17% of all gonorrhea diagnoses, though they only comprise 1% of the UK population.
The year 2008 also brought the publication of the updated NICE guidelines for antenatal care. Pregnancy may be one of the only times that many otherwise healthy women access medical care, it therefore seems an ideal time to opportunistically screen for Sexually Transmitted Infections.
The new guideline continues to recommend routine screening for certain blood borne infections (HIV & Hepatitis B) and syphilis for pregnant women. A new introduction to the guideline is the recommendation that:
“At the booking appointment, healthcare professionals should inform pregnant women younger than 25 years, about the high prevalence of chlamydia infection in their age group and provide local details for the National Chlamydia Screening Programme”.
It also adds that, although there is no current role for routine chlamydia screening in antenatal care, there is a need for further research into the benefits of screening in these patients. Patients who are 25 and over who are keen to be screened should be advised about where they can be tested.
The implications of Chlamydia in pregnancy are the same as those outside pregnancy: pelvic inflammatory disease, increased risk of infertility and ectopic pregnancy with the increased risks associated with untreated infection in pregnancy of possible preterm delivery, low birth-weight and fetal infection (ophthalmic/pulmonary). By understanding these risks we can help to advise women eligible for screening of the benefits.
Since the NICE publication, there has been a report from Australia looking at antenatal chlamydia screening. It identified those most likely to have the infection in pregnancy. In women between 16 and 25 years of age, 3.2% (95% CI 1.8 to 5.9) tested positive for Chlamydia. 44% of infections were in women who reported more than one sexual partner in the last year. The majority of cases were in those under the age of 20.
It is possible that further research [as recommended by the NICE] will confirm these findings. Until then, it seems wise to consider these results alongside the NICE guidelines to focus screening on the under 25s working further to engage those who may be at an increased risk.
In new guidelines published jointly by the British HIV association, BAASH and British Infection Society we are reminded that it is not only in obstetrics we should be considering testing for HIV. In the introduction to the guideline, it is stated that twenty four percent(24%) of HIV related-deaths occur because diagnosis was made too late for effective treatment (Late diagnosis results in a poorer response to therapy) and approximately one third of HIV positive patients are undiagnosed, leading to an increased transmission rate (in the USA it is estimated that 50 percent of infections are due to undiagnosed carriers). It is therefore essential that we play our role in encouraging patients who may be at risk to seek testing.
In obstetrics we are used to the opt-out testing of expectant mothers. It is likely that this form of testing will become more common especially in GUM clinics, termination of pregnancy services and in patients with increased risk e.g. intravenous drug users.
Amongst other groups who should be offered tests are:
- patients who tests positive for any STI (increased risk of co-infection)
- patients from a country where the prevalence of HIV is greater than 1% (or their sexual partners)
- patients presenting for healthcare where HIV, including primary HIV infection, enters the differential diagnosis (see table of indicator diseases and section on primary HIV infection
These may be the groups that do not access the traditional setting for HIV testing so it is important that we consider testing them whenever they access healthcare services e.g. as gynaecology inpatients / outpatients. For the last group in the list above it is well known that cervical cancer is an AIDS-defining illness in HIV positive patients. It may be less well known however, that HIV testing should also be considered and offered in patients found to have Vaginal Intraepithelial neoplasia (VIN) and persistent Cervical Intraepithelial neoplasia (CIN) Grade 2 or above, both of which may indicate an underlying immunosuppressive process e.g. HIV/AIDS.
As doctors, midwives and nurses we should be able to obtain consent for HIV testing.
We should [as a minimum] discuss the test and how the patient will access results. We should also remember that HIV and AIDS still carry a significant stigma. However we must inform the patient that thanks to antiretroviral treatments such as HAART, the majority of HIV positive patients are able to live normal, healthy lives. There is no requirement to disclose negative HIV tests to insurers, mortgage providers etc so there will be no negative consequences for a negative test. Patients, who test positive will be able to access treatment that may prolong their life, prevent transmission to sexual contacts and children, and reducing the risk of late detection or poor response to treatment.
It is also important that patients are aware of the window period of up to three months that may occur between contracting HIV and testing positive, this may be discussed as part of the pre-test counseling. Patients who may have been at risk during the last three months should be advised to return for testing when they are outside the window. Patients should be advised that they are at their most infectious in the first month of acquiring HIV so abstinence or as a minimum condom use is essential until they have had a negative test 3 months after any risk.
The National Chlamydia Screening programme was rolled out in 2007/2008, having grown steadily from its introduction in 2003. There are now 86 programme-areas covering 152 primary care trusts. The programme targets those under the age of 25 who are encouraged to perform self- taken vaginal swabs (female) and urine samples (male). Specimens are processed using NAAT (nucleic acid amplification test) which has a high sensitivity and specificity. Positive results and their contacts can then be treated in an attempt to reduce complications due to undiagnosed infection and reduce transmission rates.
Testing can be accessed at young people’s services, local pharmacies, pregnancy and contraception advisory services as well as numerous other locations. Local teams also target groups such as service personnel, students and clubbers at planned events to try to target the under 25s. At present 4.9% of young people have been screened nationally with between 1 in 10 and 1 in 12 of those tested, being positive for Chlamydia.
Amongst women in [2007/08] some 236,817 screens were performed nationally with 9.2 (9.1-9.3 95%CI) testing positive.
One study in 2006 modeled that, if 30% of young people are screened with 20% partner notification, Chlamydia rates may be reduced by 30% at 1 year and 70% at 5 years. It is hoped that identifying more young people with Chlamydia will reduce the transmission rate, reduce the total number of infections and possible subsequent complications (PID, Ectopic pregnancy, infertility) and associated morbidity and mortality.
Another article published in STI in 2008 demonstrated that it is not only among younger patients that sexually transmitted infections are becoming more prevalent. Although older patients make up a much smaller proportion of the total numbers of infections the number of diagnoses are growing amongst this age group as well.
The study, undertaken in the UK West Midlands showed that in 2006, patients who were 45 years and older, accounted for 3.7% of attendances at Genito-Urinary Medicine (GUM) clinics. By 2003, 4.3% of attendees were over 45.
It was however demonstrated that over this period, the number of positive results more than doubled (p
It may often be the case that we dismiss the risk of sexually transmitted infections amongst these patients, as they are perceived to be in “stable relationships” or, sexual history may not be discussed at all. However it seems that these patients are engaging in unprotected sexual contact and are acquiring STIs. It is important that we remember this, and consider alternative diagnoses for some patients over 45, perhaps altering treatment choices and morbidity. The article also suggests that while we continue to focus sexual health programmes on young people who account for the majority of diagnoses, programmes targeting older people should also be established. It is clear that “societal and healthcare attitudes, myths and assumptions about sexual activity among older people” need to be addressed.
It may be that this age group don’t use condoms as they think of them only as a form of contraception that they no longer need – many of these patients will be sterilised or post menopausal. They may be entering new relationships for the first time in 15 or more years following a long term relationship and not know how to negotiate safe sex. Either way, we can advise them on safe sexual practice and where to obtain further information and testing.
So what is the best practice in identifying and treating sexually transmitted infarctions in our patients?
For those working outside sexual health clinics it may be difficult to keep up to date with the most up to date testing and treatment recommendations. The British associations of sexual health and HIV medicine provide regularly updated guidelines on their website: www.bashh.org.
The most recent guidelines for the investigation of symptomatic and asymptomatic women are summarised in Tables 1, 2 and 3. Local policies on treatment may vary. It is therefore worth discussing any concerns with local GUM or Microbiology Department if you have any concerns. Treatment for pregnant women only varies in the treatment of Chlamydia where it is also necessary to perform a test of cure as advised below.
A full sexual history will guide as to whether an asymptomatic or symptomatic screen should be performed as well as which swabs should be taken. Outside the GUM setting, charcoal swabs may be used for culture for gonorrhea, bacterial vaginosis (BV) and trichomonas vaginalis (TV). Chlamydia NAATS kits are widely available in hospital and community.
It is important to realise that while cervical and vaginal swab samples give the highest yield they can be affected by contamination with blood. If there are concerns about this, then a urine sample may be sent along with the swabs as a “backup” sample (with endocervical sample also sent to lab). It should be remembered that in women, chlamydia is usually an endocervical (not vaginal) infection so if possible, an endocervical sample should be obtained for highest yield.
The current media focus on NHS funding regarding sexual health, as well as the continuing rise in the numbers being diagnosed with Sexually transmitted infections will continue to be important issues. Professionals outside the specialty of GUM will have to play a larger role in identifying and treating these patients.
In obstetrics, gynaecology and midwifery, we have a responsibility to the women we treat that we not only provide this care, but do so following the best current recommendations.
- A T Bodley-Tickell, B.O. (2008). Trends in sexually transmitted infections (other than HIV) in older people: analysis of data from an enhanced surveillance system. Sexually Transmitted Infections, 312-317.
- British association for sexual health and HIV,. (2006). UK National STI Screening and Testing Guideline. Retrieved April 2009, from http://www.bashh.org/documents/59/59.pdf
- British HIV Association, British association for Sexual health and HIV, British Infection Society. (2008). UK National guidelines for HIV testing 2008. British HIV Association.
- M Y Chen, C. K. (2009). Screening pregnant women for chlamydia: what are the predictors of infection? Sexually transmitted infections, 31-35.
- MedFASH. (2008). Progress and priorites – working together for higher quality sexual health. Review of the National strategy for sexual health and HIV. DOH.
- National Chlamydia Screening Programme. (2008). NCSP: Five years – Annual report of the National Chlamydia Screening Programme in England 2007/08.
- National Institute Clinical Excellence (NICE). (2008). Antenatal care: routine care for the healthy pregnant woman. NICE.
- Turner KME, e. a. (2006). Modelling the effectiveness of chlamydia screening in England. Sex Transm Inf, 496-502.
- Personal Communication: Dr Kim Botly Staff Grade Physician in Genito-urinary Medicine, Hope House.