1. BASHH 2012 UK Re-Audit of Asymptomatic Screening Dr Hugo McClean 1

2. BASHH 2012 Audit standards Sexually Transmitted Infections: UK National Screening and Testing Guidelines August 2006 http://www.bashh.org/guidelines Recommended Tests for Asymptomatic Patients This presentation builds upon the recommendations from the 2009 audit

3. BASHH 2012 Audit- presentation scheme Standards Methods Results Key messages Recommendations for improvement

4. Conclusions 2009 Audit High overall rates of testing with BASHH CEG first line recommended tests for chlamydia, syphilis and HIV High overall rates of testing for gonorrhoea in women when NAATs included Important number of cases having N. gonorrhoeae NAATs, including urine GC NAATs (45% MSM) Urethral microscopy ~ 20% men Cervical microscopy ~ 10% Most MSM tested for HepB (80%) Predominance of hepatitis C testing in MSM

5. Suggested Areas for Practice Improvement/Interventions 2009 Audit Increased documentation of discussion about oral and anal sex, as recommended in the BASHH recommendations on sexual history taking to identify which anatomical sites need to be sampled for infection Regional strategies should be considered to balance nucleic acid amplification testing for gonorrhoea with culture testing to monitor antibiotic sensitivity Increased screening for hepatitis B in MSM is needed in some regions. Increased screening for HIV is needed in some regions, particularly for women

6. Standards 6

7. Asymptomatic heterosexual men *Urethral culture only for gonorrhoea: 1194 (58%, 2-98%) **Recommended if urethral specimen not available

8. Asymptomatic MSM *Urethral culture only for gonorrhoea **Recommended if urethral specimen not available

9. Asymptomatic women * recommended if urethral specimen not available

10. Case definition No symptoms offered on presentation (either on a triage form, or similar form, or on direct questioning by a healthcare worker) Seen during a first meeting in a new or re- book episode

11. Data collection- 1 Audit interval: – Clinic policies: on day of audit – Cases seen 1 October to 31 December 2011 Data collection – Launched 7 Jan 2012 – Closed 15 April 2012 Participation: – Level 3 services: BASHH NAG Regional Chairs network – BASHH website, emails, BASHH Newsletter

12. Data collection- 2 Data submitted using an online form Clinic policy data Case note data: – Up to consecutive 40 cases* *RCP Local Clinical Audit: handbook for physicians: http://old.rcplondon.ac.uk/clinical- standards/ceeu/Documents/Local-clinical-audit-handbook-for-physicians-August-2010.pdfhttp://old.rcplondon.ac.uk/clinical- standards/ceeu/Documents/Local-clinical-audit-handbook-for-physicians-August-2010.pdf

13. Results Case, clinic, regional and national level data National aggregate composed of regional-level data Percentage of clinics in each BASHH Region meeting performance levels Overall national performance

14. Questions asked 1.Recording of oral sex: occurrence, non- occurrence, patient declined to answer, documented not asked, no record, not applicable 2.Receptive anal sex: same as for oral sex 3.Offer of HIV testing: offered & done, offered & declined, not offered, not applicable 4.Tests for hepatitis B, or immune or chronic infection or not appliacable 5.Tests for gonorrhoea 14

15. Gender and sexual preference Total 6669 cases – Women: 3321 (50%) – Men: 3348 (50%) Het men: 3020 (90%) MSM: 328 (10%) 15

16. Number (%) of clinics participating, by Region BranchNumber of cases submitted North Thames804 South East Thames602 South West511 West Midlands499 Wales487 Northern447 Yorkshire443 Anglia408 South West Thames398 North West384 Trent361 Oxford279 Wessex279 Northern Ireland205 Essex204 Cheshire and Merseyside196 Scotland162 National6669

17. Documentation about oral sex 17

18. Documentation about receptive oral sex- women 18 Percentage of cases having a record made about occurrence or non-occurrence of receptive oral sex 2009: 45% (8-65%)

19. Documentation about receptive oral sex- het men 19 Percentage of cases having a record made about occurrence or non-occurrence of receptive oral sex

20. Documentation about receptive oral sex- MSM 20 Percentage of cases having a record made about occurrence or non-occurrence of receptive oral sex 2009: 81% (50-100%)

21. Documentation about anal sex 21

22. Documentation about receptive anal sex- women 22 Percentage of cases having a record made about occurrence or non-occurrence of receptive anal sex

23. Documentation about receptive anal sex- MSM 23 Percentage of cases having a record made about occurrence or non-occurrence of receptive anal sex

24. Recording of occurrence of anal sex in heterosexual men- national data 24 Region Anal sex recorded as ‘occurred’ Anglia n=1930.5% Cheshire and Merseyside n=850.0% Essex n=940.0% North Thames n=3390.3% North West n=1620.0% Northern n=2054.4% Northern Ireland n=990.0% Oxford n=1281.6% Scotland n=681.5% South East Thames n=2771.1% South West n=2385.5% South West Thames n=1680.6% Trent n=1810.0% Wales n=2350.9% Wessex n=1260.0% Yorkshire n=1960.0% West Midlands n=2261.3% National, N=30201.2%

25. HIV testing uptake 25

26. HIV testing uptake- eligible MSM 26 Percentage of eligible MSM having an HIV test (‘not applicable’ excluded)

27. HIV testing uptake- eligible women 27 Percentage of eligible women having an HIV test (‘not applicable’ excluded)

28. HIV testing uptake- eligible het men 28 Percentage of eligible het men having an HIV test (‘not applicable’ excluded)

29. Hepatitis B testing uptake 29

30. Hepatitis B testing uptake- eligible MSM 30 Percentage of eligible MSM having a test for hepatitis B (‘not applicable,’ ‘immune,’ ‘chronic infection ’ all excluded)

31. Hepatitis B testing uptake- eligible women 31 Percentage of eligible women having a test for hepatitis B (‘not applicable,’ ‘immune,’ ‘chronic infection ’ all excluded)

32. Hepatitis B testing uptake- eligible het men 32 Percentage of eligible men having a test for hepatitis B (‘not applicable,’ ‘immune,’ ‘chronic infection ’ all excluded)

33. Gonorrhoea testing 33

34. Gonorrhoea testing- MSM, any test done 34 Percentage of MSM having any test done for gonorrhoea

35. Gonorrhoea testing- women, any test done 35 Percentage of women having any test done for gonorrhoea

36. Gonorrhoea testing- het men, any test done 36 Percentage of het men having any test done for gonorrhoea 2009: 96% (89-100%)

37. Gonorrhoea testing- women, tests done (not oropharyngeal NAAT & culture) 37 Anatomical site/test Number 2012 (%, regional range %) N=3321 Number 2009 (%, regional range %) N=2131 Cervical culture1310 (39%, 0-83%)1393 (65%, 26-94%) Vulvovaginal NAAT1289 (39%, 0-81%)244 (12%, 0-29%) Urethral culture872 (26%, 0-71%)953 (45%, 16-82%) Cervical NAAT656 (20%,1-55%)250 (12%, 0-44%) Vulvovaginal culture195 (6%, 0-34%)- Urine NAAT181 (6%, 0-16%)209 (10%,0-36%) Urethral microscopy130 (4%,0 -13%)(%,-%) Urethral NAAT45 (1%, 0-16%)33 (2%, 0-13%) Cervical microscopy7 (0.2%, 0-27%)248 (12 %,0-42%) Rectal microscopy15 (0.2%, 0-1.1%)

38. Gonorrhoea testing- women, tests done: oropharyngeal & rectal NAAT & culture 38 Anatomical site/testNumber (%, regional range % Oropharyngeal culture (all women, N=3321)151 (5%, 0-16%)  Receptive oral sex occurred, n=1038115 (11%, 0-44%) Oropharyngeal NAAT (all women, N=3321)102 (3%, 0-24%)  Receptive oral sex occurred, n=103878 (8%, 0-39%) Rectal culture (all women, N=3321)40 (1%, 0-7%)  Receptive anal sex occurred, n=17719 (11%, 0-50%) Rectal NAAT (all women, N=3321)28 (1%, 0-4%)  Receptive anal sex occurred, n=17722 (12%, 0-100%)

39. 2009 Audit. Asymptomatic women: oropharyngeal & rectal gonorrhoea culture

40. Gonorrhoea testing- MSM, tests done (not oropharyngeal NAAT & culture) 40 Anatomical site/test Number 2012 (%, regional range %) N=328 Number 2009 (%, regional range %) N=219 Urine NAAT228 (70%, 0-100%)98 (45%, 0-100%) Urethral culture 114 (35%, 9-100%)119 (54%, 9-100%) Urethral microscopy 35 (11%, 0-44%)38 (17%, 0-100%) Rectal microscopy 16 (5%, 0-44%)9 (4%, 0-25%) Urethral NAAT 8 (2%, 0-46%)7 (3%, 0-20%)

41. Gonorrhoea testing- MSM, tests done: oropharyngeal & rectal NAAT & culture 41 Anatomical site/testNumber (%, regional range %) Oropharyngeal NAAT (all MSM, N=328)164 (50%, 0-92%)  Receptive oral sex occurred, n=279150 (54%, 0-92%) Oropharyngeal culture (all MSM, N=328)170 (52%, 0-83%)  Receptive oral sex occurred, n=279152 (54%, 0-91%) Rectal NAAT (all MSM, N=328)163 (50%, 0-89%)  Receptive anal sex occurred, n=218128 (59%, 0-100%) Rectal culture (all MSM, N=328)136 (42%, 11-89%)  Receptive anal sex occurred, n=218115 (53%, 0-100%)

42. 2009 Audit. Asymptomatic MSM: oropharyngeal & rectal

43. Gonorrhoea testing- het men, tests done Anatomical site/testNumber 2012 (%, regional range %) N= 3020 Number 2009 (%, regional range %) N= 2078 Urine NAAT 2017 (67%, 17-99%)751 (36%, 0-100%) Urethral culture 972 (32%, 0-85%)1194 (58%, 2-98%) Urethral microscopy 306 (10%, 0-22%)459 (22%, 0-87%) Urethral NAAT53 (2%, 0-10%)84 (4%, 0-16%) Oropharyngeal culture 60 (2%, 0-8%)38 (2%, 0-8%) Oropharyngeal NAAT 23 (1%, 0-6%)3 (0.1%, 0-2%) Rectal culture 3 (0.1%, 0-1%)0 Rectal NAAT 6(0.2%, 0-1%)0 Rectal microscopy00

44. Key points 44 Why do we ask fewer women than men about peno-oral sex? Lack of documentation about receptive oral sex in MSM some regions Should we ask ‘het men’ about receptive anal sex? Half of female patients asked about receptive anal sex and, even when this occurred, relatively few had rectal Gc testing. Similarly, for receptive oral sex Why do fewer women (still) have an HIV test? Testing women for gonorrhoea: cervical NAAT or vulvovaginal NAAT?

45. Recommendations for improvement Review policies for gonorrhoea testing, particularly in women, and re-audit interventions aimed at improving uptake of testing Consensus on sexual history taking questions, reflected in training Consensus on anatomical site for NAAT testing, reflected in training 45

46. Acknowledgements: BASHH Regional Audit Chairs & Members Chair Hugo McClean Vice Chair Chris Carne Hon Sec Ann Sullivan Director of Development Anatole Menon- Johansson BCCG Representative Phil Kell BHIVA Representative Alison Rodger, Ed Wilkins Scotland Daniel Clutterbuck Wales Helen Baley, Sarah McAndrew, Carys Knapper Northern Ireland Say Quah Anglia Raouf Moussa Cheshire & Mersey Ravindra Gokhale Essex Gail Crowe North Thames Ann Sullivan, Alan Smith Northern Sarup Tayal North-West Ashish Sukthankar Oxford Gill Wildman South East Thames Cindy Sethi South-West Zoe Warwick South-West Thames Steven Estreich Trent Jyoti Dhar Wessex Neelam Radja, Leela Sanmani West Midlands Sashi Acharya Yorkshire Amy Tobin-Mammen Co-opted Members David Daniels, Nicola Low, Lindsay Emmett Hilary Curtis for questionnaire design, collection, collation of data, user support and production of regional & national aggregates