Availability of services for subjects of sexual assault in genitourinary medicine clinics.

The aim of this study is to gain an understanding of the services available to subjects of sexual assault at genitourinary medicine (GU medicine) clinics throughout the United Kingdom, and to determine whether these services are adequate. By means of a questionnaire, consultants in 106 clinics provided information on the number of patients who reported sexual assault and the services available to them. The study found a marked regional variation in attendances by subjects of sexual assault. However, only a minority of clinics kept accurate data (36.7% regarding female victims and 37.75% regarding male victims). The number of subjects who were aged under 16 years was disproportionately high (under 16s: 6.9% of female victims and 1.2% male victims; 16 and over: 1.3% of female victims and 0.14% of male victims). This survey highlights deficiencies in services that need to be addressed by clinics, management and the speciality.

Molecular epidemiology of genital human papillomavirus and Chlamydia trachomatis among patients attending a genitourinary medicine clinic - will vaccines protect?

High-risk subtypes of human papillomavirus (HPV) are the main causative agents of cervical cancer, for which Chlamydia trachomatis (CT) may sometimes be a co-factor. Vaccines have been developed against some subtypes of human papillomavirus and a vaccine against CT is in development. The objective of this study was to determine the prevalence of the subtypes of HPV and CT in genitourinary (GU) medicine clinic attenders. In total, 1000 consecutive patients attending the GU clinic participated in this anonymized point-prevalence study. Urethral swabs from 437 men and urethral plus cervical swabs as a single specimen from 563 women were tested for the subtypes of both organisms. Nested major outer membrane protein (MOMP) polymerase chain reaction detected CT chromosomal DNA in 44/437 (10%) of the men and 73/563 (13%) of the women. Genotypes E, F, and D were the most common. In all, 55/437 (13%) of men and 244/563 (43%) of women were infected with at least one high-risk HPV type. In conclusion, the new HPV vaccines, Gardasil and Cervarix, would have protected against 58% and 45%, respectively, of the high-risk subtypes found in women in this population. The rate of high-risk HPV infection (43%) found in women in this study raises concern.

Survey of prioritizing/triaging of appointments in genitourinary medicine clinics in the UK: a British Co-operative Clinical Group survey.

A questionnaire was circulated to all lead genitourinary (GU) medicine physicians in the UK in November 2003 to obtain data on access, waiting times and triaging. Of the 143 responders, 92.3% departments had limited access to some or all GU medicine clinics. Where access was limited, 5.3% had no identifiable process in place to see urgent patients. The mean waiting times in clinics with an open appointment system only for a routine female and male appointment were 2.9 weeks and 2.8 weeks (range 2 days-10 weeks), respectively, and for an urgent appointment, two days (range same day-14 days), for both sexes. The survey has raised concerns that a number of departments did not consider as urgent for prioritizing, patients with documented untreated gonorrhoea, syphilis, or HIV, or contacts of patients with these conditions. This survey has highlighted a need for the national specialist society to provide guidance on prioritizing patients where access is limited.

Screening, diagnosis and management of early syphilis in genitourinary medicine clinics in the UK.

New diagnoses of syphilis in the UK increased eight-fold between 1997 and 2002. This study, conducted in 2002, demonstrated that 31% of clinics were not confident of their expertise to obtain an adequate specimen for dark ground microscopy (DGM), and 35% were not confident of their expertise to detect treponemes on DGM. In all, 64% of clinics had observed adherence problems in HIV-positive patients treated with parenteral regimens, as against 42% with oral regimens. Also, 51% of clinics waited more than a week for the results of initial serological tests for syphilis, and 88% of clinics waited more than a week for confirmatory test results. Other concerns include the failure to perform syphilis serology consistently whenever HIV-positive patients were at risk, and the widespread use of doxycycline as a therapy for syphilis in HIV-positive patients despite concerns that this is not known to be fully treponemicidal in cerebrospinal fluid.

Testing for HIV antibody: a comparison of two services offered in a genitourinary medicine clinic.

Rates of screening for sexually transmissible infections in patients using different services provided by a genitourinary medicine clinic for testing for HIV antibodies are presented. Those patients whose primary reason for attending the clinic was HIV antibody testing and used the same day result (SDR) service were significantly less likely to be screened for other infections than those using the normal waiting time (NWT) service, (P < 0.00001). This was true for both males and females. Of those patients screened for other infections in the SDR and NWT groups 29% and 35% respectively were found to have a sexually transmitted infection. It would appear that an SDR service offers little benefit for the majority of patients as only a few patients would not have had an HIV antibody test had the SDR not been available.

Improved sexual history taking in the 2012 BASHH asymptomatic screening re-audit.

Effective asymptomatic screening for sexually transmitted infections is an important public health service because a significant proportion of sexually transmitted infections do not present with symptoms. In 2009, the National Audit Group of the British Association of Sexual Health and HIV (BASHH) audited the management of asymptomatic patients and recommended increased documentation about oral and anal sex, regional strategies for nucleic acid amplification test (NAAT) use for gonorrhoea, improved screening for hepatitis B in men who have sex with men and an increase in screening for HIV. The 2012 audit used web-based forms to collect submissions from 180 consultant-led centres (65% response rate) that included episodes of care from 6669 asymptomatic patients. An improvement was demonstrated for all the areas measured during the 2009 audit. A doubling of gonorrhoea testing using NAATs was seen and yet 10% of asymptomatic patients continued to have microscopy despite these tests not being recommended by BASHH guidelines. This audit recommends universal adoption of gonorrhoea NAATs across the United Kingdom.

Prevalence, clinical features and quantification of genital non-viral infections.

We conducted a study of the prevalence, clinical features and microscopy findings, by retrospective case-notes survey, of six non-viral organisms, among 1718 attendees at a genitourinary (GU) medicine clinic in England. An in-house assay for six non-viral infections was used and quantitation of ureaplasmas performed. The prevalences of the six organisms were: Chlamydia trachomatis (CT), 7.1%; Neisseria gonorrhoeae (NG), 0.6%; Mycoplasma genitalium (MG), 1.0%; Trichomonas vaginalis, 0.2%; Ureaplasma urealyticum, 16.1%; Ureaplasma parvum, 35.6%. Among men (but not women) there were significantly raised odds ratios compared with that for U. parvum, for the symptom of discharge with CT, 7.30; MG, 6.43; NG 19.29; dysuria with CT, 5.89 and MG, 5.95; and the microscopy finding of >4 pus cells per high power field with: CT, 7.22; MG, 4.58 and NG 22.31. Evaluation of a possible link between quantitation of U. urealyticum and urethritis did not confirm research findings elsewhere.

Chlamydial partner notification in the British Association for Sexual Health and HIV (BASHH) 2011 UK national audit against the BASHH Medical Foundation for AIDS and Sexual Health Sexually Transmitted Infections Management Standards.

This paper reports on chlamydial partner notification (PN) performance in the 2011 BASHH national audit against the British Association for Sexual Health and HIV (BASHH) Medical Foundation for AIDS Sexual Health (MedFASH) Sexually Transmitted Infection Management Standards (STIMS). There was wide regional variation in level 3 clinic PN performance against the current standard of index case-reported chlamydial PN, with 43% (regional range 0-80%) of clinics outside London meeting the ≥0.6 contacts seen per index standard, and 85% of clinics (regional range 82-88%) in London meeting the ≥0.4 standard. For level 2 clinics, 39% (regional range 0-100%) of clinics outside London met the ≥0.6 standard, and 43% (regional range 40-50%) of clinics in London met the ≥0.4 standard. Performance for health-care worker (HCW)-verified contact attendance is also reported. New standards for each of these performance measures are proposed for all level 3 clinics: ≥0.6 contacts seen per index case based on index case report, and ≥0.4 contacts seen per index case based on HCW verification, both within four weeks of the first partner notification interview. The results are discussed with regard to the importance of adoption of standards by commissioners of services, relevance to national quality agendas, and the need for development of a national system of PN quality assurance measurement and reporting.

UK national re-audit of sexual history-taking.

A focused repeat national audit of sexual history-taking was conducted in genitourinary (GU) medicine clinics in the UK in 2010, addressing several areas of practice under-performance identified in the baseline 2008 national audit. The case-notes of 4285 patients were audited. An increase in documentation was observed for all measures, except legibility which was unchanged. Despite the overall improvement, several measures (chaperone offer, condom usage and four of five aspects of HIV risk assessment) remained below target.

UK national audit against the key performance indicators in the British Association for Sexual Health and HIV Medical Foundation for AIDS and Sexual Health Sexually Transmitted Infections Management Standards.

A national audit of practice performance against the key performance indicators in the British Association for Sexual Health and HIV (BASHH) and HIV Medical Foundation for AIDS Sexual Health Standards for the Management of Sexually Transmitted Infections (STIs) was conducted in 2011. Approximately 60% and 8% of level 3 and level 2 services, respectively, participated. Excluding partner notification performance, the five lowest areas of performance for level 3 clinics were the STI/HIV risk assessment, care pathways linking care in level 2 clinics to local level 3 services, HIV test offer to patients with concern about STIs, information governance and receipt of chlamydial test results by clinicians within seven working days (the worst area of performance). The five lowest areas of performance for level 2 clinics were participating in audit, having an audit plan for the management of STIs for 2009-2010, the STI/HIV risk assessment, HIV test offer to patients with concern about STIs and information governance. The results are discussed with regard to the importance of adoption of the standards by commissioners of services because of their relevance to other national quality assurance drivers, and the need for development of a national system of STI management quality assurance measurement and reporting.

National audit of asymptomatic screening in UK genitourinary medicine clinics: case-notes audit.

A national audit of screening of asymptomatic patients seen in UK genitourinary medicine clinics in 2009 was conducted against the national guidelines. Data were aggregated by regions and clinics in regions, allowing practice to be compared within and between regions, as well as to national averages and against national guidelines. The case-notes of 4428 patients were audited. Performance was over 80% against the national guidelines for screening of asymptomatic heterosexual men, men who have sex with men (MSM) and women for chlamydial, gonorrhoeal, syphilis and HIV infections. However, the recommended method of endocervical culture for gonorrhoea was performed in only 65% of women, with a further one-quarter being screened with endocervical or vulvovaginal nucleic acid amplification tests (NAATs). Although significant NAAT use for gonorrhoea was seen in all groups, testing for gonorrhoea by culture is still recommended as a first-line test on invasive samples. Over 80% of MSM, who were not known to be immune, were screened for hepatitis B. Urethral microscopy was performed in 22% of heterosexual men and 17% of MSM, and cervical microscopy in 12% of women.

National audit of asymptomatic screening in UK genitourinary medicine clinics: clinic policies audit.

Of clinics responding to the audit, 99 and 97% have policies that are compliant with the British Association for Sexual Health and HIV National Guidelines for testing of asymptomatic men and women for HIV and syphilis, respectively. All clinics offer men, and all but one clinic offer women, screening for chlamydial infection with nucleic acid amplification tests (NAATs), as recommended by the guidelines. However, for gonorrhoea screening one-third of clinics offer men urine or urethral NAATs, and one quarter of clinics offer women endocervical, vulvovaginal or urinary NAATs, and not endocervical culture, and these practices are not compliant with the guidelines. Eight clinics did not specify whether they routinely offer testing for gonorrhoea in women. One-third of clinics routinely perform rectal and oropharyngeal screening for gonorrhoea in men who have sex with men (MSM), but fewer screen for chlamydia, regardless of sexual history which is stated as a determinant of offering screening at these anatomical sites. Finally, one-fifth of clinics offer urethral microscopy to asymptomatic heterosexual men and MSM, and about one half of clinics offer urethral culture for detection of gonorrhoea in asymptomatic women, even though these practices are not compliant with the guidelines.