Clinical reviews on sexual health

GP training programme improves HIV testing rates

22 Nov 2018Registered users

Sexual Health in Practice (SHIP), an educational programme tailored to general practice, increased GPs’ rates of HIV testing.

Intrauterine device use associated with reduced risk of cervical cancer

22 Oct 2018Registered users

Women who had used an intrauterine contraceptive device (IUD) were found to have a lower risk of cancer of the cervix in a systematic review and meta-analysis.

Patients at risk of STIs not attending sexual health services

25 Jul 2018Registered users

More than 80% of women and nearly 90% of men who reported having unsafe sex in the past year did not consult sexual health services, findings from the third National Sexual Attitudes and Lifestyles (Natsal 3) study have shown.

Exploring the barriers to fitting IUCDs in primary care

25 Jun 2018Registered users

A general practice study has revealed a reluctance among GPs and practice nurses to fit intrauterine contraceptive devices (IUCDs). An online survey was sent to 69 practices in the south east of England and 208 individuals responded. More than two-thirds of the respondents were GPs and nearly a third were nurses. When asked about statements relating to potential barriers to providing or recommending IUCDs, respondents who were not trained to fit IUCDs were more likely to identify with more barriers than those who had been trained.

Composition of vaginal microbiota may increase risk of chlamydia infection

22 May 2018Paid-up subscribers

 Lactobacillus iners-dominated vaginal microbiota was associated with increased susceptibility to Chlamydia trachomatis infection in women, in a Dutch nested case-control study.


Chlamydia infection

A case of recalcitrant bacterial conjunctivitis

05 Dec 2013

It is important to be vigilant for retained foreign bodies as a cause of recalcitrant bacterial conjunctivitis, even in the absence of foreign body sensation. A relapsing-remitting history should prompt referral to an ophthalmology department. All patients presenting with a red eye should be asked specifically about contact lens wear, and causes of conjunctivitis other than those bacterial in nature — such as viral and chlamydial infections or allergy — should be borne in mind.

Improving screening for chlamydia in primary care

21 Mar 2013Paid-up subscribers

Financial incentives combined with practice-based support, audit and feedback helped improve GP screening rates for chlamydia in practices in South London.

Which patients are being screened for chlamydia?

08 Aug 2011Registered users

The National Chlamydia Screening Programme (NCSP) appears to be reaching young people at increased risk of chlamydia, according to a recent study. Says Dr Richard Ma, commenting on the study, 'While it might be difficult to imagine GPs and nurses offering chlamydia screening to any 18-24 year old they see, they might be more likely to offer the test if they perceive that the young person is at higher risk of sexually transmitted infection. This may explain the differences in positivities between the NCSP and the general population.'

Risk factors for chlamydia infection in contacts

23 Mar 2011Registered users

 Young age, having sex more than once with the infected partner, and a greater number of partners are all risk factors for chlamydia in contacts, a study from a GUM clinic has shown. A questionnaire-based, cross-sectional study was carried out using contacts of chlamydia cases attending a GUM clinic in Leicester. Only those who were verified as a contact case and willing to have a chlamydia test were included. 'This study is too small to trigger any changes to current practice. Larger studies are needed to weigh up the risks and benefits of switching to a policy of offering epidemiological treatment just to high-risk contacts, the researchers conclude. However, this study helps to reinforce the importance of partner notification as an important tool to reduce onward infection of STIs such as chlamydia. Not only do we need to convey the importance to the index case that their partners need testing and treatment, but we also need to remember to test and treat the partners if they present to us in general practice.'

PID guidelines not followed in primary care

24 Jan 2011Registered users

Although the management of pelvic inflammatory disease (PID) is improving in general practice, most patients are still failing to be treated according to national guidelines, a UK study has shown. The British Association of Sexual Health and HIV (BASHH) has published guidelines for the management of PID which includes tests that are routinely available in primary care and antibiotics that are easily obtained from community pharmacists. The investigators used information from the General Practice Research Database (GPRD), a database of anonymised longitudinal patient records from 460 general practices. 'A total of 3,797 women were coded as having a first episode of PID during the study period; the incidence appeared to decrease from 19.3 to 8.9/10,000 person-years. The National Chlamydia Screening Programme had just been rolled out at the beginning of the study period; in theory, screening and treating for chlamydia may prevent cases of PID but this relationship cannot be substantiated from this study alone.'

Point of care chlamydia tests are not reliable

24 Nov 2010Registered users

Point of care (POC) diagnostic tests for chlamydia have low sensitivity and positive predictive value, a study from the Netherlands has found. The researchers evaluated the diagnostic performance of three POC tests: Handilab-C, Biorapid CHLAMYDIA Ag test and QuickVue Chlamydia test comparing them with the nucleic acid amplification test (NAAT), the gold standard for diagnosing chlamydia. All the POC tests were commercially available and had a CE mark (Conformitée Européene). 'The authors described these tests as having ‘alarmingly poor performance' particularly in terms of sensitivity and positive predictive value; they also state that these tests are not ready for widespread use. Clearly in practice, this would result in infections being missed and unnecessary treatment for those with false-positive results.'

Tracking down chlamydia infection in primary care

21 Sep 2010Paid-up subscribers

Infection is usually asymptomatic. Sexually active people aged under 20 in the UK are the group most likely to have a positive result if tested. This is probably because this group changes partners more frequently. However, there also appear to be immunological factors which make infection more persistent in the young. Transmission occurs through vaginal, rectal or oral sex. It can also be vertically transmitted. Untreated chlamydia infection can result in complications including pelvic inflammatory disease (potentially leading to infertility or ectopic pregnancy), sexually acquired reactive arthritis and epididymo-orchitis. There is controversy over important questions such as the likelihood of complications developing and, hence, what sort of control measures are appropriate. Some countries, for example England, have set up screening programmes while others, such as Scotland, have elected not to. [With external links to the evidence base]

Chlamydia screening needs to improve targeting of young men

20 Jul 2010Registered users

The UK's National Chlamydia Screening Programme (NCSP) is an opportunistic screening programme for chlamydia in under-25s that has been rolled out in England since 2003. All anonymised data from the NCSP from April 2006 to March 2007 were analysed in the South East region. Only 1% of men under 25 and 3% of women in this age group in the South East underwent chlamydia screening in the fourth year of the national programme. Community contraception services, youth services and general practice detected the majority of positive results in both sexes, nearly half of positive men and almost two-thirds of positive women. 'The authors suggest that a strategy that can give access to both high numbers of the target population and a wide variety of individuals needs to be developed. They call for greater engagement with general practice, contraceptive services and youth clinics - all of which can generate large volumes with relatively high positivity compared with other settings. '

Pharmacists selective when offering chlamydia screening with emergency contraception

22 Jun 2010Registered users

Pharmacists participating in a scheme to offer chlamydia screening to young women requesting emergency contraception (EC), did not offer it comprehensively. They were less likely to offer testing to women who were married, in a long-term relationship or who had recently been tested. 'The pharmacists surveyed here undertook specific training in sexual health and chlamydia screening in their own time and offered the service free of charge to their customers and for this they are to be commended.However, that screening was offered preferentially implies that at times they were acting expediently and at others were making value judgements. The tendency to decline to offer screening to girls under 16 is an opportunity missed. It could be argued that some screening is better than none but it does highlight the need for proper training and adequate resources if inroads into chlamydia infection are to be realised.'

Chlamydia screening can reduce rates of pelvic inflammatory disease

18 May 2010

'While the POPI study does not prove beyond doubt the effectiveness of a chlamydia screening programme, it does prove there is some evidence that it can reduce incidence of PID. Also of interest is that it helps clinicians not to dismiss taking a sexual history in a woman who has had a chlamydia test as she might have been exposed to risks since the last test.'

Contact tracing vital to prevent chlamydia reinfection

23 Jul 2008Registered users

Letters. The greatest risk of reinfection for the index case is from the current partner.

HIV infection

Patients endorse opt-out testing for HIV in primary care

20 Mar 2014Registered users

Patients like the idea of opt-out HIV testing at GP surgeries but some have concerns about confidentiality, a qualitative UK study has found. The study used focus groups drawn from Brighton, which has a diagnosed HIV prevalence of 7.59 per 1,000 patients, to elicit attitudes and concerns regarding HIV opt-out testing. [With external links to current evidence]

Do rapid HIV tests improve frequency of testing?

23 Oct 2013Registered users

Rapid HIV tests did not result in a sustained increase in testing, although the rate of initial HIV testing increased by a third in a study of men who have sex with men (MSM).This non-blinded randomised control study was based in the Melbourne Sexual Health Centre. The men were aged >18, reported having sex with a man within the previous year, had had a negative HIV test within the previous two years, and were attending for clinical care. [With external links to current evidence]

Which indicator conditions predict HIV?

25 Jul 2013Registered users

A UK study using The Health Improvement Network (THIN) database to identify symptoms and clinical diagnoses associated with HIV infection has assessed their predictive value in diagnosing HIV in primary care. The THIN database contains anonymised patient records from 386 UK general practices; these include sociodemographic data, diagnoses, treatments, clinical measurements, laboratory results, secondary care referrals and hospital diagnoses. [With external links to current evidence]

Male injecting drug users who have sex with men at greater risk of HIV

24 Jun 2013Registered users

Men who inject drugs (IDUs) and have sex with men (MSM) have a four-fold higher risk of HIV than those who only have sex with women (MSW), a national survey has found. Prevalence of hepatitis C (HCV) was also a third higher in the former group. IDUs in England, Wales and Northern Ireland have been recruited into a voluntary unlinked anonymous cross-sectional survey annually since 1990. The survey includes an oral swab for HIV and HCV and a questionnaire on demographics and risk behaviours. A total of 8,671 male IDUs who reported having had sex and injecting drug use in the previous 12 months took part in the survey for the first time between 1998 and 2007. Median age was 29 and median period of injecting drug use seven years.

Use of opiate substitution linked to fall in HIV transmission

21 Feb 2013Registered users

Methadone treatment was associated with more than a 50% reduction in the risk of HIV transmission in injecting drug users, in a meta-analysis published in the BMJ.

Educational intervention increases HIV testing in primary care

28 Jan 2013Paid-up subscribers

Training GPs and practice nurses using a multifaceted educational intervention can improve HIV testing rates in general practice, a longitudinal study has found. Sexual Health in Practice (SHIP) addresses the barriers to HIV testing and teaches a systematic clinical approach to testing. It covers four situations where HIV tests may be offered: patient request; opportunistic testing for those found to be high risk through history taking; diagnostic testing for those with relevant symptoms; and screening. SHIP training, which aims to attract GPs and practice nurses irrespective of whether they have an interest in sexual health, was commissioned by Haringey PCT in North London. [With external links to current evidence]

Exploring staff attitudes to providing HIV testing outside specialist areas

30 Oct 2012Registered users

Staff perceptions about the time needed to carry out HIV testing and to manage the results appear to be the main barriers to expanding testing to non-traditional settings, the qualitative arm of the HINTS study has found. Many healthcare staff also had preconceptions about patients’ attitudes to testing which were not borne out when patients were asked their views. Focus groups were conducted in the pre- and post-testing phases. Four themes emerged from the focus group discussions: stigma of HIV; targeted versus routine testing; special skills and operational issues. [With external links to current evidence]

Patients willing to accept HIV tests in different clinical settings

30 Oct 2012Registered users

The majority of patients across all sociodemographic groups are happy to be offered HIV tests irrespective of the clinical setting, the HINTS study has found. The study was set in four locations in London where diagnosed HIV prevalence exceeds 2 per 1,000: an emergency department (ED), an acute care unit (ACU), a dermatology outpatient clinic (OPD), and a large primary care centre (PC). In the first three settings, tests were offered by seconded local sexual health and permanent staff and a small number of non-clinical staff; only GPs were involved in the PC arm. [With external links to current evidence]

Diagnosing HIV in patients with glandular fever like symptoms

20 Sep 2012Paid-up subscribers

Offering HIV tests to patients who present with glandular fever-like illness would improve the detection rate of HIV, a primary care study has shown. The prevalence of HIV infection in patients presenting with glandular fever-like illness in practices in Lambeth and Southwark was studied. Samples submitted to the local laboratory for a glandular fever screen between April 2009 and June 2010, with and without a concomitant HIV request, were anonymised and retrospectively tested for HIV. [With external links to current evidence]

GPs could play a key role in shared HIV care

25 Apr 2012Registered users

Primary care teams can make a valuable contribution to counselling, testing and treatment for HIV, a systematic review has shown. The authors looked at various shared-care models of HIV involving primary and secondary care. [With external links to current evidence]

Early ART improves life expectancy in HIV patients

24 Jan 2012Registered users

Life expectancy, at age 20, for patients treated for HIV increased by more than 15 years from 1996 to 2008, a large cohort study from the UK has shown. Mortality rates from HIV have decreased dramatically over the past few decades through the use of antiretroviral therapy (ART). The risk of death in patients treated successfully with ART is now similar to that of people with unhealthy lifestyles such as heavy smokers or drinkers, those who are obese or have chronic conditions such as diabetes. HIV infection has itself become a chronic disease with a good prognosis, provided treatment is commenced early and the patient maintains adherence to therapy. [With external links to current evidence]

GUM clinics show wide regional variation in distribution

22 Nov 2011Registered users

The vast majority of the population in England live within 30 minutes of their nearest GUM clinic, only 3% have to travel further. However, there is a wide variation in geographical distribution with more difficult access in the South West and eastern regions.  Writes Richard Ma: 'Despite apparently good access to sexual health services for the majority of the population, levels of STIs, unplanned pregnancies and HIV remain high. According to this paper, no one in London has to travel more than 30 minutes to a GUM clinic and yet it has high rates of unplanned pregnancies, STIs and HIV. One explanation is that even if a clinic is within 30 minutes’ travelling time, those who need the service most may not access it; also, someone who may benefit from a sexual health screen may not travel to a GUM clinic. It remains inequitable that some GPs offer a full range of sexual health services whereas others do not. Although timely access and close proximity may address sexual health needs, commissioners may need to work on improving the coverage of sexual health services in non-GUM settings such as general practice, community contraceptive clinics, youth services and pharmacies, where people are more likely to be offered a check-up opportunistically when they attend for another reason.'

Which GP and patient characteristics influence HIV testing?

19 Sep 2011Paid-up subscribers

GPs who are under 35 and working in metropolitan areas are more likely to offer HIV tests, a study from Australia has found. Patients deemed to be at risk by their GP or who present for screening are most likely to be tested. The study used data from a cross-sectional, national survey of GP activity called BEACH (Bettering the Evaluation and Care of Health). This database has been running since 2000; each year, approximately 1,000 GPs from a national, rolling sample are recruited. [With external links to current evidence]

Patients' expectations of sexual health services in primary care often go unmet

25 May 2011Registered users

Patients who present to general practice with a suspected STI expect to be offered tests, given information and a formal referral to a GUM clinic if care is not offered on site. However, a qualitative study found that these expectations were often not met and many would prefer to be treated at a GUM clinic in future. 'It is refreshing to see that the public chose to see their GP in the first instance for sexual health matters. They expected their sexual histories to be explored, genital examinations to be done, and tests for STI and HIV to be offered. It is unfortunate, however, that some of the patients did not get what they wanted from general practice. It feels to me that we as GPs sometimes create barriers so that people do not get the care they need and it doesn't just apply to sexual health. It is the old chestnut: PUNs and DENs - patients' unmet needs might be doctors' educational needs. Let's try to do something about it.'

Increasing uptake of HIV tests in men who have sex with men

09 May 2011Paid-up subscribers

The term men who have sex with men (MSM) encompasses a diverse group of men of all ages, ethnicities and cultural backgrounds. Their sexual behaviour is equally diverse: while some MSM have exclusively male partners, others have partners of both genders or identify themselves as heterosexual but have occasional casual sexual encounters with men. MSM may be involved in the commercial gay scene, may visit cruising environments in public places or may be in monogamous sexual relationships. There were an estimated 415,600 MSM aged 15-44 in the UK in 2007. The estimated prevalence of HIV in this group was 5.2%. Of 60,050 people aware of their HIV-positive diagnosis in the UK, 26,050 (43%) were MSM. A further 9,000 MSM in the UK are estimated to be infected with HIV but unaware of their diagnosis.

Risk of HIV transmission from MSM undergoing treatment

21 Feb 2011Registered users

There is a one in five risk of  men who have sex with men (MSM) being treated for HIV passing on the infection to their male partners if they do not use condoms. Using data from a cohort of MSM in the Netherlands, researchers used mathematical modelling to predict the probability that a man will infect his uninfected male partner over the course of first-line antiretroviral treatment. [With external links to current evidence]

Healthcare professionals' views a barrier to HIV testing

20 Dec 2010Registered users

The attitude of doctors and healthcare administrative staff is a greater obstacle to extending HIV testing than that of patients, a study has found.This paper set out to explore the attitudes of patients to being offered HIV testing in Cornwall where the prevalence is reported as 32 per 100,000 population. [With external links to current evidence]

Antiretroviral therapy reduces rates of HIV-1 transmission

20 Oct 2010Registered users

Giving antiretroviral therapy (ART) to patients with HIV-1 could reduce transmission rates in the population. The Partners in Prevention HSV/HIV Transmission Study enrolled heterosexual adults from seven African countries (Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia) co-infected with HIV-1 and herpes simplex virus type 2 (HSV-2), along with their HIV-1 seronegative partners. [With external links to current evidence]

HIV testing has increased in primary care

15 Jan 2010Registered users

HIV testing of men and women increased 11- and 19-fold respectively in general practice between 1995 and 2005. However, testing rates still remained relatively low. [With external links to current evidence]

HIV-positive patients consult GPs at same rate as general population

15 Jan 2010Registered users

 Patients with HIV consult their GP on a similar scale to the wider population, a large retrospective cohort study has found. The study used data from the UK General Practice Research Database (GPRD), which involved 348 practices, yielding 5,504 person-years of follow up for known HIV-positive individuals. Using the data that were available for a total of 1,438 men and 751 women recorded as HIV positive, the following were estimated: GP and nurse consultation rates for HIV patients compared with rates for the GP-registered population; the cost of GP and nurse consultations; consultation rates for selected morbidities and the proportion of prescriptions in 2005 that included a medication considered to present potential for serious adverse interactions with HIV medications. [With external links to current evidence]

HIV testing in primary care will help improve early diagnosis

15 Nov 2009Registered users

HIV is now a treatable medical condition. In all, 77,000 people are known to be infected with HIV in the UK. However, 28% are unaware of their infection and are therefore unable to access treatment. They are also at risk of unwittingly passing the virus on to others. Many patients who present late to care have been to see their GP in the months or years leading up to their diagnosis but have never been tested for HIV. In the UK National guidelines on HIV testing have recently been published by the RCP to help improve provision and uptake of HIV testing in both primary and secondary care settings.

Rapid HIV tests in primary care are acceptable to patients

01 Oct 2009Registered users

Current UK national guidelines recommend an increase in HIV testing in primary and secondary care settings to improve early diagnosis. However, I think for this to be successfully rolled out in primary care, there need to be adequate incentive structures in place to encourage uptake, and effort should be concentrated in areas of high HIV prevalence such as London, Brighton and other urban areas. [With external links to current evidence]


HPV infection and cervical screening

HPV vaccination uptake lowest in young women at greatest risk

22 Apr 2014Registered users

Teenage girls most at risk of cervical cancer are least likely to be offered HPV vaccination and, those who are, less likely to complete the course, a cross-sectional study of sexual health service users has found. [With external links to current evidence and summaries]

Genital warts decline in wake of HPV vaccination

24 Jun 2013Paid-up subscribers

A large study from Australia has demonstrated a significant reduction in genital warts following introduction of the quadrivalent HPV vaccination programme in mid-2007. Eight sexual health services provided retrospective data from 2004 to 2011. Data were collected on demographics, sexual behaviour and diagnosis of genital warts; two large clinics also collected self-reported HPV vaccination status of new patients from 2009. The number of patients diagnosed with new genital warts was presented as a proportion of new patients seen. The proportion of Australian born patients who tested positive for chlamydia was used as a comparison.

High HPV prevalence found in young women

20 Jun 2012Paid-up subscribers

Sexually transmissible HPV infection is highly prevalent in the British population, particularly among young women, the second National Survey of Sexual Attitudes and Lifestyles (Natsal-2) has revealed. HPV DNA was detected in 29% of urine samples from women and 17% of samples from men. Natsal-2 used a probability sample of the population aged 16-44 years, resident in Britain. A total of 11,161 people were interviewed for the study.

Genital warts fall following quadrivalent HPV programme

24 Jan 2012Registered users

The number of new cases of genital warts in women and heterosexual men under 21 has fallen dramatically in Melbourne in the wake of the Australian HPV vaccination programme using a quadrivalent vaccine.

HPV testing is an effective screening tool for cervical cancer

27 Aug 2009Paid-up subscribers

HPV testing is a more accurate method of predicting cervical cancer than cervical cytology, a large multinational cohort study has shown. After six years' follow-up the rate of cervical cancer was significantly lower in women negative for HPV than in women with negative cytology results. Pooled data on 24,295 women from seven screening programmes in six European countries, including the UK, were analysed. All had a cytological smear and an HPV test at baseline.

HPV prevalence underestimated

01 Jul 2007Paid-up subscribers

A study from the USA reinforces the recent recommendation of the US Advisory Committee on Immunization Practices that the new human papillomavirus (HPV) vaccine should be offered to all girls aged 11 and 12.


Hepatitis infection

Should men who have sex with men be screened for hepatitis C?

21 Feb 2013Paid-up subscribers

Reports of acute HCV infection in HIV-positive men who have sex with men (MSM) have emerged where sexual exposure was the only risk factor. In a systematic review, HIV-positive MSM had approximately four times the risk of acquiring acute HCV infection compared with HIV-negative MSM. The data suggest it would be reasonable to consider routine screening for HCV in HIV-positive MSM.

Mildly raised ALT levels may point to hidden hepatitis C

12 Dec 2012Paid-up subscribers

Patients with slightly elevated alanine aminotransferase (ALT) levels are at increased risk of hepatitis C infection and should undergo further investigation, a study from the Netherlands has concluded.

High hepatitis C prevalence in injecting drug users

01 Sep 2007Paid-up subscribers

Hepatitis C (HCV) infection is common in illicit drug users, and can lead to severe morbidity and mortality. Although all illicit drug users may put themselves at risk of acquiring HCV infection, a new study confirms that those with a long history of drug use and those who inject (particularly with shared needles or using preparation equipment such as spoons) are most at risk.