The Primary Care Consultation and Sexual Health

Aims of today Why is it important? Overcoming barriers Assessing risk Reducing risk Scenarios

Which symptoms might be caused by a STI Vaginal/urethral discharge Dysuria Abdominal pain Conjunctivitis lymphadenopathy Pharyngitis Weight loss Post-coital bleeding Uveitis Seborrhoeic dermatitis Arthritis Aortic regurgitation Diarrhoea Pelvic pain Genital ulcer Flu-like illness

Which symptoms might have a cause other than a STI Vaginal/urethral discharge Dysuria Abdominal pain Conjunctivitis lymphadenopathy Pharyngitis Weight loss Post-coital bleeding Uveitis Seborrhoeic dermatitis Arthritis Aortic regurgitation Diarrhoea Pelvic pain Genital ulcer Flu-like illness

Beware! 50-80% chlamydia is assymptomatic

What are the risk factors for STIs <25 Single 2 or more sexual partners in the last 6 months No condoms Sexual orientation City dwellers Ethnicity

How is Primary Care different from GUM? Not everyone is at risk of an STI Patients may not see themselves as being at risk Patients may not expect questions about sex They come with several unrelated problems

What are the barriers to taking a sexual health history Patients accompanied Under 16 Patient may not want to talk about it. Fear of inclusion on records Fear of others seeing records May not be on the patient’s agenda Clinician anxiety or embarressment It will take too long… Patient doesn’t see themselves at risk

Why is it important? Being assymptomatic doesn’t stop transmission May not be recognised as STI if symptoms are mild or unrelated to the genital area Untreated STI’s have serious consequences

When is it appropriate to talk about STI risk? New patient registration Contraception Pre- IUD/IUS Travel clinic Any symptoms which are suggestive of an STI If we don’t ask, they won’t tell

What are your barriers to talking about sexual health in a consultation?

PRINCIPLES OF DOING A SEXUAL RISK ASSESSMENT

WHO IS AT RISK?

Youth Sexual inexperience Beliefs system What patients believe about you What you believe about patients Time Unsure what to say ????

Reasons for doing a risk assessment  If no apparent risk  stops unnecessary tests  If at risk  increases positivity  More specific education  Repeat testing if new risk  good management of positive results

“so you’re in a stable relationship aren’t you?”

General Be matter of fact Practice some scripts Consider the patient’s beliefs & barriers Work with the patient so that decisions are collaberative Counsel patients appropriately Maintain confidentiality Be non-judgmental Seek their consent to explore furhter

Move to a shared understanding  Does the patient think they are at risk?  Do you think they are at risk

Raising the issue out of the blue In the symptomatic patient

An STI is one possible diagnosis of many Make it clear that you do not know if the patient is at risk until you have established their risk

“ sometimes people who present with symptoms like this may have a sexually transmitted infection. Would it be OK if I asked you a few questions to see if you might be at risk?”

Out of the blue - The assymptomatic patient

Depersonalise & routine “ as part of our contraception checks, we normally ask patients if they might be at risk of a sexually transmitted infections so that we can offer appropriate testing. Would it be OK if I asked you a few questions to see if you are at risk?”

Share knowledge “As you’re probably aware, Chlamydia is a common sexually transmitted infection in people of your age. Would it be OK if I asked you a few questions to see if you might be at risk?”

Accompanied patients 1.18 year old girl with her friend 2.15 year old girl with her mother 3.17 year old girl with mild learning difficulties with her mother

Accompanied patients “ I need to ask some quite sensitive questions which are easier if you are by yourself. Would it be OK if your friend/partner/spouse waited outside?”

Remember Not everyone is at risk…… …….but some are. We won’t know an individual’s risk if we don’t ask.

Partner history Do you have a sexual partner at the moment? Is that a man/woman/both? How long have you been together? Have you or your partner had any other partners in that time? When was the last time you had sex?

HIV questions Have you ever had a sexual partner who comes from another country? Which country? Have you ever wondered if any partners were at risk of HIV?

Avoid apportioning blame “ if a result is positive, it doesn’t tell us where the infection came from – just that the infection is in the relationship. Many infections can cause no symptoms and you have both had previous partners, so all we can say is that at some point it has been introduced into the relationship.”

Condom use Do you use a condom? Do you always use a condom? Have you ever had problems using condoms?

Don’t make assumptions May be appropriate to explore additional risks – sex with those overseas – internet contacts – overseas travel – ivdu – sex workers – Specific sexual practices

THE INFECTIONS

Chlamydia Women Symptoms – 80% asymptomatic – PCB/IMB – Purulent vaginal discharge – Lower abdominal pain – Dysuria Signs – Normal – Cervicitis, muco-purulent discharge – Local complications eg Bartholin’s cyst Men Symptoms – >50% asymptomatic – Urethral discharge – Dysuria – Testicular/epididymal pain – Proctitis Signs – Normal – Urethral discharge – Local complications eg epididymitis

Chlamydia testing Nucleic acid amplification tests (NAAT) replacing PCR Male – First void urine vs swab Women – Self-taken lower vaginal swab or endocervical swab

Chlamydia treatment Recommended Azithromycin 1g stat (assess risk vs benefit if pregnancy possible) Doxycycline 100mg bd for7 days (not if pregnant/breastfeeding) Alternative Pregnancy/breastfeeding – Erythromycin 500mg for 14/7 Alternative – Erythromycin 500mg qds 7 days – Ofloxacin 200mg bd or 400mg od for 7 days

Patient information Chlamydia is sexually transmitted Often assymptomatic, but left untreated has potentially serious complicaitns Need to see and treat sexual partners Abstain from intercourse, until completion of therapy or 7 days after azithromycin Need to complete treatment Advice on safer sexual practice

Do I need to retest? Not pregnant Routine test of cure are not indicated in >25’s Pregnant/ Rx with erythromycin 5 weeks after Rx or 6 weeks if given erythromycin Under 25’s

Gonorrhoea Men Symptoms – Urethral infection-85% symptomatic within 10 days – Rectal infeciton – 80% assymptomatic – Pharyngeal infection – 90% assymptomatic Women Symptoms – Cervical infection assymptomatic – 50% vaginal discharge –50% lower abdo pain <25% – Rectal infection- 80% assymptomatic – Pharyngeal infeciton – 90% assymptomatic

Men Mucoid-> purulent urethral discharge Meatitis Non- genital signs – eg rectal discharge, pharymgitis, – Disseminated infectino Women Cervicitis Mucoid -> purulent discharge Cervical excitation Signs PID Non genital signs

Tests Men Urine – First pass urine for NAAT Urethral swab Self taken LVS – for NAAT Endocervical swab – NAAT & culture

Treatmetn Onward referral to GUM

HIV Why screen? 33% patients in Cumbria present late Incidence rising in heterosexual population HIV is a treatable disease Early treatment improves length & quality of life Reduction of onward transmission Reduction in vertical transfer Medical benefits outweigh negatives eg life insurance

Approx third of HIV positive patients are unaware they are positvie Many are attending GP surgeries and not being offered appropriate tests

Acute infection – sero-conversion Asymptomatic HIV related illnesses AIDS defining illness Death

Window period to seroconversion Modern tests will detect majority of infected individuals at one month A negative result at 4 weeks post exposure is reassuring Further test at 12 weeks

Common presentaitons Sero-conversion – `50-80% of patients develop self-limiting flu-like illness, sometimes with a rash 2-4 weeks after infection HIV risk history approached sensitively may help identify those at greatest risk

Symptomatic HIV disease – “weight loss and sweats” – “cough and SOB” – “intractable skin conditions eg seborrhoeic dermatitis, eczema, psoriasis – HIV associated conditins Key to diagnosis is clinical suspicion based on risk factors, so we need to be asking about possible risk of HIV

2008 guidelines Patients with an STI Sexual partners of those known to be positive MSM and female sexual contacts IVDU’s People from countries of high prevalence, people who have sex with individuals from high prevalence Those who present with a health problem likely to be HIV related

Guidelines for screening Be confident! Have a script ready HIV is treatable illness Risk assessment of susceptible groups Explain how result will be given

Over to you