Special interest: Sexual health

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

 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.'

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.'

'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.'

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]

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.

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]

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]

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]

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.'

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.'

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]

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]

 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]

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]

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.

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.

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.

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.