As good as it gets? Retention in care of people newly diagnosed with HIV at the Sydney Sexual Health Centre.

A retrospective review of all new HIV positive patients attending the Sydney Sexual Health Centre in 2012 and 2013 was performed to ascertain the retention in care rates, proportion that achieved viral suppression, number of SMS reminders sent and counselling uptake. Ninety-six patients had a retention rate of 66%. Thirty-three patients (34%) were not retained in care, 16 (17%) were knowingly attending another healthcare service with 17 (18%) categorised as lost to follow up. Counselling referrals had a 74% (71/96) uptake (95%CI: 5.08-69.69, P<0.001), with SMS reminders sent in 97% (93/96) of cases (95%CI: not possible with zero count cells, P=0.038). Overall, the clinic performed well compared with international standards but the lost to follow-up rate remains a concern.

Loss to follow-up in the Australian HIV Observational Database.

BACKGROUND: Loss to follow-up (LTFU) in HIV-positive cohorts is an important surrogate for interrupted clinical care, which can potentially influence the assessment of HIV disease status and outcomes. After preliminary evaluation of LTFU rates and patient characteristics, we evaluated the risk of mortality by LTFU status in a high-resource setting. METHODS: Rates of LTFU were measured in the Australian HIV Observational Database for a range of patient characteristics. Multivariate repeated measures regression methods were used to identify determinants of LTFU. Mortality by LTFU status was ascertained using linkage to the National Death Index. Survival following combination antiretroviral therapy initiation was investigated using the Kaplan-Meier (KM) method and Cox proportional hazards models. RESULTS: Of 3,413 patients included in this analysis, 1,632 (47.8%) had at least one episode of LTFU after enrolment. Multivariate predictors of LTFU included viral load (VL)>10,000 copies/ml (rate ratio [RR] 1.63; 95% CI 1.45, 1.84; ref ≤400), time under follow-up (per year; RR 1.03; 95% CI 1.02, 1.04) and prior LTFU (per episode; RR 1.15; 95% CI 1.06, 1.24). KM curves for survival were similar by LTFU status (P=0.484). LTFU was not associated with mortality in Cox proportional hazards models (univariate hazard ratio [HR] 0.93; 95% CI 0.69, 1.26) and multivariate HR 1.04 (95% CI 0.77, 1.43). CONCLUSIONS: Increased risk of LTFU was identified amongst patients with potentially higher infectiousness. We did not find significant mortality risk associated with LTFU. This is consistent with timely re-engagement with treatment, possibly via high levels of unreported linkage to other health-care providers.

Low yield of anogenital examination among asymptomatic clients of an urban sexual health clinic.

BACKGROUND: The use of self-collected specimens to test for sexually transmissible infections (STI) has reduced the opportunity for physical examination. Physical examination has been found to be of limited value in asymptomatic heterosexual women and men; however, prior studies have excluded higher risk populations. We performed a retrospective cross-sectional study to determine the diagnostic yield of physical examination among all clients attending our sexual health service. METHODS: The Sydney Sexual Health Centre database was used to identify asymptomatic clients attending for the first time between January and June 2009. Demographic and behavioural data were extracted from the database for all clients. Medical records were then manually reviewed to determine the number and nature of diagnoses related to the examination and whether this varied by sex and sex of sexual partners. RESULTS: Of the 590 clients included, 450 (76%) received anogenital examinations. Ten (2.2%; 95% confidence interval 1.1-4.1%) STI were found, including four cases of cervicitis, four of anogenital warts and two of molluscum. Nineteen (4.2%) other non-STI conditions were detected, mostly in heterosexual women and men who have sex with men (MSM). CONCLUSION: Physical examination of asymptomatic clients attending our sexual health clinic was of limited value, even among higher risk individuals such as MSM. Sexual health clinics should direct resources currently used to examine clients towards increasing the STI testing rate.

Screening of HIV-infected patients for non-AIDS-related morbidity: an evidence-based model of practice.

OBJECTIVE: To develop guidelines to facilitate management of HIV infection as a chronic disease within the setting of a sexual health or other HIV outpatient clinic. METHODS: We undertook a literature search to identify published guidelines and expert panel commentaries on screening and managing non-AIDS comorbidities in the general and HIV-infected population. We developed evidence-based guidelines for screening and management of non-AIDS comorbidities in HIV-positive clients attending the Sydney Sexual Health Centre (SSHC) that could be used in other HIV outpatient settings. RESULTS: Guidelines have been developed that describe the recommended tests and an interpretation of results, and outline actions to take if abnormal. A summary document can be placed in the medical notes to record completed tests, and resources such as lifestyle modification pamphlets and cardiovascular risk assessment tools made easily available in clinics. CONCLUSIONS: These guidelines are being used by nurses and doctors to facilitate the management of HIV as a chronic disease in the SSHC. This represents a significant shift in practice from the traditional role of a sexual health clinic, and is likely to become increasingly important in resource-rich countries such as Australia where individuals with HIV are expected to live beyond their seventh decade. This model could be used in other HIV outpatient settings including general practice.

Trichomonas vaginalis infection among women in a low prevalence setting.

OBJECTIVES: Trichomonas vaginalis has become rare in Australian cities but remains endemic in some remote regions. We describe the prevalence and associations of infection among women attending an urban Australian sexual health clinic. METHODS: A retrospective case control study was conducted with women diagnosed with T. vaginalis at Sydney Sexual Health Centre between January 1992 and December 2006. Proforma medical records for all women were reviewed to extract demographic, behavioural and diagnostic variables using a predefined data collection instrument. RESULTS: Over the 15-year period, 123 cases of T. vaginalis were diagnosed, with a prevalence of 0.40%. Factors independently associated with infection were older age, vaginitis symptoms (adjusted odds ratio (AOR) 6.47; 95% confidence interval (CI), 3.29-12.7), sex with a partner from outside Australia (AOR 2.33; 95% CI, 1.18-4.62), a concurrent (AOR 3.65; 95% CI, 1.23-10.8) or past (AOR 2.67; 95% CI, 1.28-5.57) sexually transmissible infection, injecting drugs (AOR 7.27; 95% CI, 1.43-36.8), and never having had a Papanicolaou smear (AOR 7.22; 95% CI, 2.81-18.9). CONCLUSIONS: T. vaginalis infection was rare in women attending our urban clinic. Rarity, combined with an association with sex outside Australia, points to imported infections accounting for a large proportion of T. vaginalis infections in an urban population. The association with never having had cervical cancer screening, along with injecting drug use, likely reflects an increased prevalence in those with reduced access to health services or poor health seeking behaviours.

Chlamydia and associated factors in an under 20s antenatal population.

INTRODUCTION: Detection and treatment of genital chlamydia trachomatis infections in pregnancy have been shown to reduce the risk of premature rupture of membranes, and post-partum endometritis and reduce the risk to the newborn of conjunctivitis and pneumonitis. Identification of factors associated with chlamydial infection in pregnancy could be used to develop criteria for routine chlamydia screening for some pregnant women. No national screening strategy exists around genital Chlamydia trachomatis infection. METHODS: We undertook a review of the medical records of all young women (aged 20 years or younger) attending the RPA Women and Babies Young Parents Clinic for antenatal care between January 2003 and June 2006. This group was chosen as RPA Women and Babies routinely offers testing for C. trachomatis to women attending the Young Parents Clinic. Data extracted included age, country of birth, language spoken at home, postcode of usual residence, marital status, educational level, change of sexual partners within the past 12 months, consistency of condom use and history of sexually transmissible infections. RESULTS: Two hundred and twelve of the 365 eligible pregnant women were screened for genital C. trachomatis, of whom 29 were positive. A rate of 13.7% genital chlamydia infection was found in this population of young pregnant women. CONCLUSIONS: Results from this study indicate that the rate of chlamydia infection (13.7%) is high in women aged 20 years or younger and that the most important risk factor is young age. These findings support recent recommendations that all women 25 years and younger are screened for C. trachomatis in pregnancy.