An effective strategy to diagnose HIV infection: findings from a national audit of HIV partner notification outcomes in sexual health and infectious disease clinics in the UK.

OBJECTIVES: Partner notification (PN) is a key public health intervention in the control of STIs. Data regarding its clinical effectiveness in the context of HIV are lacking. We sought to audit HIV PN outcomes across the UK. METHODS: All UK sexual health and HIV services were invited to participate. Clinical audit consisted of retrospective case-note review for up to 40 individuals diagnosed with HIV per site during 2011 (index cases) and a review of PN outcomes for up to five contacts elicited by PN per index case. RESULTS: 169/221 (76%) clinical services participated (93% sexual health/HIV services, 7% infectious diseases/HIV units). Most (97%) delivered PN for HIV. Data were received regarding 2964 index cases (67% male; 50% heterosexual, 52% white). PN was attempted for 88% of index cases, and outcomes for 3211 contacts were audited (from an estimated total of 6400): 519 (16%) were found not to be at risk of undiagnosed HIV infection, 1399 (44%) were informed of their risk and had an HIV test, 310 (10%) were informed of the risk but not known to have tested and 983 (30%) were not informed of their risk of HIV infection. Of 1399 contacts tested through PN, 293 (21%) were newly diagnosed with HIV infection. Regular partners were most likely to test positive (p<0.001). CONCLUSIONS: HIV PN is a highly effective diagnostic strategy. Non-completion of PN thus represents a missed opportunity to diagnose HIV in at-risk populations. Vigorous efforts should be made to pursue PN to identify people living with, and at risk of, HIV infection.

Variation in partner notification outcomes for chlamydia in UK genitourinary medicine clinics: multilevel study.

OBJECTIVES: To compare different ways of measuring partner notification (PN) outcomes with published audit standards, examine variability between clinics and examine factors contributing to variation in PN outcomes in genitourinary medicine (GUM) clinics in the UK. METHODS: Reanalysis of the 2007 BASHH national chlamydia audit. The primary outcome was the number of partners per index case tested for chlamydia, as verified by a healthcare worker or, if missing, reported by the patient. Control charts were used to examine variation between clinics considering missing values as zero or excluding missing values. Hierarchical logistic regression was used to investigate factors contributing to variation in outcomes. RESULTS: Data from 4616 individuals in 169 genitourinary medicine clinics were analysed. There was no information about the primary outcome in 41% of records. The mean number of partners tested for chlamydia ranged from 0 to 1.5 per index case per clinic. The median across all clinics was 0.47 when missing values were assumed to be zero and 0.92 per index case when missing values were excluded. Men who have sex with men were less likely than heterosexual men and patients with symptoms (4-week look-back period) were less likely than asymptomatic patients (6-month look-back) to report having one or more partners tested for chlamydia. There was no association between the primary outcome and the type of the health professional giving the PN advice. CONCLUSIONS: The completeness of PN outcomes recorded in clinical notes needs to improve. Further research is needed to identify auditable measures that are associated with successful PN that prevents repeated chlamydia in index cases.

UK National Audit of chlamydial infection management in sexual health clinics. case notes audit: information-giving, partner notification and follow-up.

Verbal information-giving is good, but only half of cases were reportedly given written information on chlamydia. Follow-up by 'phoning or texting (43%) was as common as follow-up in clinics (39%). About one-fourth of cases did not have follow up, with no recall for around 60% of these cases. Advice about partner notification (PN) was provided by a health adviser or other suitably trained health professional to 91% of cases, and the method of PN was documented for 92% of these cases. PN outcome was not documented for about 25% of these cases. There was no information on the chlamydial status of sexual contacts of about half of cases, and no information about the treatment status of sexual contacts of about 40% of cases. The average number of contacts screened per index was 0.52 outside London and 0.29 for the London Regions, levels below those suggested in the National Guideline.

UK National Audit of chlamydial infection management in sexual health clinics. clinic policies audit.

There was a wide range of activity and chlamydial diagnoses between the 177 clinics that responded. Most (92%) clinics have nucleic acid tests for chlamydial diagnosis. Different practitioners largely share roles in providing advice to patients about partner notification, treatment adherence, safer sex advice and abstinence. Most (97%) clinics have information leaflets about chlamydia, although about 30% of clinics lack leaflets containing information about antibiotics and hormonal contraception. About two-third clinics follow the National Guideline recommended interval for providing a test of cure where this is indicated. Only 18% of clinics routinely ask patients to reattend, with 40% having a policy of no routine follow-up and 62% using telephone or text follow-up. These categories were not mutually exclusive. Most (86%) of the 146 English clinics had a local Chlamydia Screening Programme coordinator for their Primary Care Trust area, although cooperation varies, with cooperation over treatment of 70% and Programme policy of 62%.

UK National Audit of chlamydial infection management in sexual health clinics. case notes audit: demography, diagnosis and treatment.

The case notes of cases of genital chlamydial infection were audited against the UK National Guideline. This was the first web-based and the largest national audit to date, with 193 clinics in all UK Regions contributing data. About half of all cases had no symptoms, with about one-third attending for routine or asymptomatic screens; suggesting significant provision of screening by clinics that might be managed differently to reduce workload. Nucleic acid amplification tests (NAATs) are now well established for chlamydial detection in UK clinics, with 93% of cases having genital NAATs. Azithromycin is now more commonly used than doxycycline (54% vs. 37%). Of 26 pregnant women, 20 were treated with azithromycin, suggesting that most prescribers treating pregnant women consider that erythromycin is not an adequate alternative to azithromycin. Most women had NAATs obtained from sites recommended by the Guideline, with 93% of women who had genital NAATs having these from the cervix or vulvovaginal area.

BASHH 2016 UK national audit and survey of HIV testing, risk assessment and follow-up: case note audit.

This national audit demonstrated discrepancies between actual practice and that indicated by clinic policies following enquiry about alcohol, recreational drugs and chemsex use. Clinics were more likely to enquire about risk behaviour if this was clinic policy or routine practice. Previous testing was the most common reason for refusing HIV testing, although 33% of men who have sex with men had a prior test of more than three months ago. Of the group declining due to recent exposure in the window period, 21/119 cases had an exposure within the four weeks prior to presentation, but had a previous risk not covered by previous testing. Recommendations include provision of risk assessments for alcohol, recreational drug use and chemsex, documenting reasons for HIV test refusal, provision of HIV point-of-care testing, follow-up for cases at higher risk of HIV and advice about community testing or self-sampling/testing.

Yorkshire regional audit of hepatitis B vaccination.

Practice related to hepatitis B vaccination in Yorkshire genitourinary medicine clinics was audited against targets based on the offer and uptake of vaccination by men who have sex with men (MSM) set by the National Strategy for Sexual Health and HIV (NSSHHIV). Of 254 eligible cases, 226 (93%) were offered vaccination, but only 187 (77%) were offered it at their first visit. Uptake of the first dose of vaccine was 83%, 56% and 82% among eligible MSM, injecting drug users (IDU) and commercial sex workers (CSW), respectively. Of the 193 cases who commenced vaccination, uptake of the third dose was 49%, 29% and 24% among eligible MSM, IDU and CSW, respectively. The super-accelerated course was most commonly prescribed, and completion of a three-dose course of this regimen was superior to the accelerated and standard courses. However, more patients having the accelerated and standard regimens had anti-surface antibodies greater than 10 IU/L compared with the super-accelerated regimen. Improved recording of risk factors and provision of written information about vaccination, as well as a robust recall system to improve the completion rates of all regimens, are needed.

UK national audit of sexual health care for people with HIV infection: clinic policies.

A national audit of the sexual health care for people with HIV infection (PWHIV) was conducted in genitourinary medicine clinics and other clinics providing care for PWHIV in the UK in the summer of 2006. Data were aggregated by region and clinic, allowing practice to be compared between regions, as well as to national averages and against various guidelines. In this, the first of two papers, clinics were surveyed on their local policies. In total, 126 clinics participated. Only 38 clinics (30%, regional range 0-60%) had written local care pathways on management of sexually transmitted infection in PWHIV, while 73 (58, 20-100%) had unwritten policies. This compares with the national standard that 100% of service providers should be able to provide documentation of local care pathways for sexually transmitted diseases in people with HIV. Clinics should consider creating policies especially where standards are not being met.

UK national audit of sexual health care for people with HIV infection: case-notes audit.

The case-notes of 3210 patients with HIV infection were audited. A sexual history was documented within four weeks before or after initial HIV diagnosis in 69% of cases (regional range 45-84%), and in the six months before attendance during the audit interval in 34% (12-53%). An offer of tests for sexually transmitted infections was documented within four weeks before or after HIV diagnosis in 58% (30-83%), and in the prior six months in 28% (14-47%). Syphilis serology was offered in the previous three months to 45% (14-100%) of cases resident in syphilis outbreak areas and to 25% (7-62%) of other cases. Hepatitis B testing was performed for 98% (95-100%) of cases and for hepatitis C, for 91% (79-100%). Cervical cytology results in the past year were documented for 73% (43-94%) of eligible women. Considerable inter-regional variation in performance exists. Interventions are needed to improve the sexual health care of people with HIV infection.

Which measure of contact tracing performance? -- using audit as the evidence base.

Different measures of contact tracing were computed in a large UK regional audit, and good correlation was found between the percentage of index cases with at least one contact seen and other measures of contact tracing. The importance of definition in the writing of standards to inform clinical practice is emphasized.

UK National Audit of Early Syphilis Management. Clinics audit: screening for and management of early syphilis.

Data were provided by 131 clinics, and 56% of cases were managed in clinics in the London regions in 2003. Three clinics (2%) do not routinely screen new patients for syphilis, and 28 clinics (21%) do not routinely screen 'rebook' patients who have had a new partner. More than 80% of clinics routinely conduct cardiovascular and neurological examinations, although chest radiography is only performed by 50% of clinics and lumbar puncture by 13%. Only 19 (14%) clinics indicated not routinely using the recommended procaine penicillin G (PPG) regimen or one- or two-dose benzathine penicillin G (BPG) regimens for early syphilis, with 57% providing two doses of BPG 2.4 g, 40% providing PPG 750 mg for 10 days, and 15% providing one dose of BPG 2.4 g. Only seven clinics (5%) indicated that they provided treatment for early syphilis with PPG that is inferior to that recommended in the national guidelines. Only 18 clinics specified using the recommended dose and duration (or in excess of this) of PPG for neurosyphilis for cases with HIV infection. Provision for management of severe penicillin reaction is good, although few patients are desensitized. All clinics report that contact tracing for early syphilis is provided, and is mainly the responsibility of health advisers. Compared with auditing outcomes, audit of management policies overestimated performance in contact tracing and provision of dark ground microscopy.

UK National Audit of Early Syphilis Management. Case notes audit: diagnosis and treatment.

A national audit of 781 early syphilis cases presenting during 2002-03 in UK genitourinary medicine clinics was conducted in late 2004, organized through the Regional Audit Groups. Data were aggregated by region and National Health Service trust, allowing practice to be compared between regions, between trusts within regions, as well as to national averages and the UK National Guidelines. An enzyme immunoassay was used to diagnose 695 (89%) cases (regional range 18-100%). Use of a non-treponemal test was not recorded for 44 (6%) cases. Dark ground microscopy was used in the diagnosis of only 80 (29%) primary cases. Uptake of HIV testing was 77% (range 69-94%). Nationally, 527 (67%) treatments were parenteral, with almost equal use of benzathine penicillin G for 262 (50%, range 0-97%) cases and procaine penicillin G (PPG) for 260 cases (49%, range 3-100%). There were 14 (5%) treatments with less than the recommended 750 mg dose of PPG. One hundred and five (40%) PPG treatments were with greater than 750 mg and/or for longer than 10 days of which 76 (72%) were for early latent syphilis and/or cases with HIV infection. One hundred and ninety two (86%, range 0-100%) of all oral treatments were with doxycycline. The recommended regimen of 100 mg doxycycline twice daily for 14 days was used for 104 (53%) cases; the other 91 (47%) treatments were with a variety of regimens, mainly treatments with larger doses and/or longer treatment intervals and some combination treatments. Fourteen (2%) cases were not treated; treatment was not reported for seven (0.9%) and not known for 10 (1.3%) cases, who were treated at other centres.

UK National Audit of Early Syphilis Management. Case-notes audit: contact tracing, information giving, follow-up and outcomes.

Contact tracing was provided for 683/781 (87%, regional range 57-97%) cases, and identified 997 traceable contacts of whom 511 (51%) were seen, short of the recommended standard of 60%. However, the performance range for this standard was 26-70%, with seven regions achieving 60% or more. Of 511, 215 (42%, range 3-73%) contacts had syphilis. Treatment completion was recorded for 691 (88%, range 71-100%) cases, and resolution of lesions for 348/469 (74%, range 40-96%) cases. Nationally, 419/764 (55%, range 37-70%) cases were recorded as having a two dilution (four-fold) or greater decrease in non-treponemal test titre within 3-6 months after treatment; not achieving this titre decrease was mainly attributable to non-attendance for follow-up and failure of titre levels to fall. Follow-up of infectious syphilis in UK genitourinary medicine clinics is poor and falls far short of that recommended by National Guidelines. Only 16 (2%) cases had follow-up at intervals approximating to 1, 2, 3, 6 and 12 months, and only 312 (40%, range 5-61%) cases attended at least two follow-up visits. Only 17 (7%) of all 236 oral treatments (including switches to oral treatment), and 33 (27%) of 123 cases with HIV infection were recorded as designated annual follow-up. Further work is needed to determine factors that account for the wide variation between regions in contact tracing and follow-up performance.

A cross-sectional survey of treatment choices for anogenital warts.

This was a cross-sectional survey that collected data relating to management of anogenital warts (AGW) during a single-patient visit only at genitourinary medicine clinics. Single-agent use of cryotherapy, podophyllotoxin and trichloroacetic acid (TCA) were the most common treatment modalities, accounting for over two-thirds of all modalities used. Podophyllin, alone or in combination with other agents, was used for about 20% of first-line treatments. Podophyllin was included in about 15% of all treatment modalities. Guidelines for the management of AGW continue to recommend the use of podophyllin, but this may need to be modified in the light of recent publications. Podophyllin, TCA, podophyllotoxin or combinations of these agents are commonly used to treat keratinized warts. About 11% of all treatments involved a combination of two or more agents.

Information-giving to patients with genital warts at a genitourinary medicine clinic: a baseline assessment.

Aspects of information-giving to patients with a first episode of genital warts attending a large UK genitourinary medicine clinic on three or more occasions were assessed using a questionnaire survey employing correlational and between-groups analyses. The main outcomes measured were levels of, and interrelationships between, patients' perceptions of information received about genital warts, accuracy of knowledge, quality of interaction with clinic personnel, written information, patients' level of anxiety and demographic variables. Patients with genital warts have good basic knowledge about this condition, although understanding about several complex issues is poor. Educational level was positively correlated with accuracy of knowledge about genital warts. Although ease of communicative interaction with information-givers was positively correlated with perceived information given, no relationship was found between the latter and actual knowledge about genital warts. Anxiety levels and receiving written information were largely uncorrelated with accuracy of knowledge about genital warts. This study suggests that while patients' perception of information received may relate to more satisfactory interaction with information-givers, actual knowledge may be a more important measurable outcome. More interventional work is needed to determine how the information-giving process for genital warts can be optimized.

A multidistrict audit of the management of chlamydial PID in genitourinary medicine clinics in Yorkshire.

In response to recent reviews of practice of pelvic inflammatory disease (PID) management, a multidistrict audit involving eight genitourinary clinics within the Yorkshire region was carried out. This audit reports the referral patterns of patients, physical signs and microscopy findings at the first genitourinary medicine (GUM) clinic attendance, antibiotic treatment and follow-up data as well as health adviser involvement and partner participation for 68 patients diagnosed with chlamydial PID. Twenty-eight (41.2%) patients presented with symptoms of less than or equal to four weeks duration, partner notification was recorded as being carried out for all patients and at least one partner was documented as having been treated in 57 (83.8%) patients. There is, however, a wide variation in the antibiotic regimens used for treatment and their duration.

A multi-district audit of the management of syphilis in genitourinary medicine clinics in Yorkshire.

An audit against standards and guidelines of a representative sample of syphilis cases managed in genitourinary medicine clinics in Yorkshire was carried out. Satisfactory serological endpoints could be determined for about two-thirds of treated early and less than one-third of treated late syphilis cases. HIV antibody testing was obtained for less than half of all cases. Recently available national guidelines suggest inadequacy of both the dose and duration of treatments with procaine penicillin of asymptomatic late syphilis cases where lumbar puncture was not carried out. The diagnosis and management of syphilis is complex, and this audit demonstrates the importance of the systematic approach developed by genitourinary medicine clinic and laboratory services.

Accelerating the audit cycle: data gathering, analysis and dissemination of results by electronic methods. The third Yorkshire audit of genital chlamydial management.

An electronic database was used as an audit tool by a peripatetic audit or to collect data on the management of genital chlamydial infection from genitourinary medicine clinics. A paper proforma was used to obtain data on clinic facilities. The database generated pre-specified quantitative reports for comparison to national standards and guidelines, as well as comparison of performance between clinics and to a previous regional audit. Feedback and discussion took place to identify interventions intended to improve practice. This methodology allowed for rapid dissemination of the audit findings to clinics.