1. How can Health Care Assistants & Practice Nurses increase STI & HIV screening in primary care Dr Jane Hutchinson 5 th March 2015

2. Learning objectives Know the key facts about the common STIs including symptoms, treatment & local prevalence rates Know what tests to use & how to take them to screen for common STIs in asymptomatic patients Understand why screening for STIs is important Develop some strategies to manage patients who opt out of testing Consider some issues specific to young people Know about the work of Step Forward & how to refer to that organisation Understand ‘You’re Welcome’ accreditation

3. Screening for STIs in the new patient check How many of you are involved in doing this? How are patients informed that they will be offered STI screening? What responses do you get from patients to the offer of STI screening? How do you manage these responses? What might you say to a patient who opts out of testing? Why do we recommend STI screening for everyone in Tower Hamlets? What else can you do to encourage patients to accept testing? What things do you need to think about in relation to young people? – From the point of view of the YP – From the point of view of the professional

4. The Sexual Health enhanced service contract Some key aims of this contract are to: – reduce rates of STIs among people of all ages in TH by increasing rates of diagnosis & treatment – reduce spread of STIs Your network or practice earns: – £15 for every Chlamydia & Gonorrhoea test you take – £10 for a blood test which screens for some or all of Syphilis, Hepatitis B & HIV – £177.75 for vaccinating someone against Hepatitis B if they are at risk of acquiring it sexually Many of you will be offering the screening tests as part of the new patient check Remember to enter the patient onto the Sexual Health Template to ensure payment is received by your practice

5. Key facts about 5 important STIs

6. Key facts about common STIs Chlamydia Gonorrhoea Syphilis Hepatitis B HIV

7. Chlamydia (CT) 10,442 15-24 year olds had a Chlamydia test in TH in 2013; 6% were positive Men >50% asymptomatic Symptoms – Urethral discharge – Dysuria – Testicular pain Complications – Epididymo-orchitis Incubation period is 2 weeks NAATs test on first void urine after holding urine for 30 mins Treat with azithromycin or doxycycline Women 70% asymptomatic Symptoms – Vaginal discharge – Lower abdominal pain – Abnormal vaginal bleeding Complications – Chronic pelvic pain – Pelvic Inflammatory Disease – Infertility – Ectopic pregnancy Incubation period is 2 weeks NAATs test on self taken vulvo- vaginal swab Treat with azithromycin or doxycycline

8. Gonorrhoea (GC) 271.5 per 100,000 population diagnosed with GC in TH in 2013 Men 80% urethral discharge Symptoms – Dysuria – Testicular pain Complications – Epididymo-orchitis Incubation period is 2 weeks NAATs test on first void urine after holding urine for 30 mins Treat with ceftriaxone injection plus oral azithromycin Women 50% asymptomatic Symptoms – Vaginal discharge – Abnormal vaginal bleeding – Lower abdominal pain Complications – Pelvic Inflammatory Disease – Bartholin’s abscess Incubation period is 2 weeks NAATs test on self taken vulvo vaginal swab Treat with ceftriaxone injection plus oral azithromycin

9. Syphilis Approx. 34 per 100,000 population diagnosed with syphilis in TH in 2013 Symptoms – Primary: genital ulcer – Secondary: rash – Latent: none – Tertiary: affects heart, brain & soft tissues Complications – Multiple affecting any part of the body Diagnosis – Blood test Treatment – Penicillin injections or oral doxycycline

10. Hepatitis B 1.4% of 1975 people of south Asian origin tested in East London diagnosed with chronic Hep B infection Can have acute or chronic infection Symptoms & complications – Acute infection: jaundice, pain over liver; vomiting; sometimes no symptoms most people make full recovery and become immune – Some develop Chronic infection: can lead to cirrhosis and liver cancer Diagnosis – Blood test Treatment: – chronic infection can be treated with anti-virals

11. HIV TH is considered a high prevalence area – 6.4 people in every 1000 population aged 15-59 have HIV infection – (across whole of UK it is 2.8 per 1000) Symptoms & complications: – Primary infection – 60% have flu like illness – Then asymptomatic for months or years – As immune system damaged by HIV, person starts to develop health problems which can affect any part of the body including rashes, chronic diarrhoea, infections & tumours Treatment – antiretrovirals Diagnosis – Blood test

12. Herpes Not included in sexual health NIS If you are examining a patient you may see it Which leads onto which swabs you should use…

13. Swabs (A: VTM - GREEN All virology GUM only) B:UTM - RED All virology sample types outside of GUM C: Transwab - PURPLE (used to be Orange) Micro M,C+S e.g. High vaginal swab

14. Screening for STIs in the new patient check

15. Suggestions of things you could say to patients who opt out of sexual health screening There are high rates of STIs in TH and many people have them without knowing that they do Many people with infections don’t know they have them because they don’t have symptoms (eg Chlamydia: >50% males & >70% females are asymptomatic) Some STIs can be cured and others can be controlled by having appropriate treatment

16. Suggestions of things you could say to patients who opt out of sexual health screening These are routine tests which we offer to everyone who has ever been sexually active Did you know there are health benefits of knowing you have an STI? – You can access treatment for yourself – You can prevent yourself developing complications of the infection – You can reduce the chances of transmitting the infection to someone else

17. What do young people want or need?

18. Step Forward

19. Case scenarios Dr Jane Hutchinson

20. Case 1 30 year old married British-born Bengali man registers with practice His wife is already registered She is also Bengali They have been married for 3 years & are trying to have a baby At NPC he declines sexual health testing

21. Case 1 One year later his wife attends booking visit at ante-natal clinic She is tested for HIV along with other routine bloods Her HIV test comes back positive She cannot identify any risk factors in her own past; her husband is her only sexual partner

22. Case 1 She attends local HIV clinic and is started on HIV treatment to prevent her passing the virus to her baby Partner notification is discussed with her She has already told her husband and he is refusing to have a test Health advisor at HIV clinic talks to her husband and he accepts testing His HIV test is also positive After further discussion with the Health Advisor he admits to having sex with men on occasions

23. Case 2 Craig who is 17 years old attends for his new patient check with his dad His dad refuses STI screening on his behalf stating that it is not necessary because he doesn’t have a girlfriend

24. Case 2 6 weeks later his 16 year old girlfriend, Penny, attends the practice with lower abdominal pain and is diagnosed with Pelvic inflammatory disease Her chlamydia test is positive The GP discusses partner notification with her and she discloses that her boyfriend is Craig He attends for screening and is also found to have Chlamydia

25. Or Case 2 v2 Craig who is 17 years old attends for his new patient check with his dad His dad refuses STI screening on his behalf stating that it is not necessary because he doesn’t have a girlfriend

26. Case 2 v2 6 weeks later his 16 year old girlfriend, Penny, attends the practice with lower abdominal pain and is diagnosed with Pelvic inflammatory disease Her Chlamydia & Gonorrhoea tests are both positive The GP discusses partner notification with her and she discloses that her boyfriend is Craig They are both advised to attend a GUM clinic for – confirmation of the Gonorrhoea diagnosis – appropriate treatment for Gonorrhoea (injection & tablets)

27. Case 2 v2 At GUM clinic Craig discloses that he is unsure of his sexuality and has had unprotected anal sex with men on a couple of occasions Both Craig & Penny confirmed to have Chlamydia & Gonorrhoea What other issues need to be considered here?

28. Or Case 2 v3 Craig who is 17 years old attends for his new patient check with his dad His dad refuses STI screening on his behalf stating that it is not necessary because he doesn’t have a girlfriend

29. Or Case 2 v3 You gave Craig a leaflet about sexual health as part of the new patient registration information He is worried that he may have an infection but didn’t know where to go to find out 2 weeks later Craig has taken note of the offer of STI screening He makes an appointment to come back on his own to see the Practice Nurse

30. Case 3 39 year old white woman who works as a solicitor registers with your practice She declines sexual health screening at new patient check 2 years later she develops liver problems and is found to have chronic Hepatitis B infection On further questioning she states that she briefly injected drugs in her late teens