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Removing the stigma

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VOL: 97, ISSUE: 46, PAGE NO: 61

Alison Kilcoin, RGN, DipHE, is domiciliary family planning sister, Southend-on-Sea Family Planning Services, Essex

Chlamydia trachomatis is the most common curable sexually-transmitted infection (STI) in the UK (Greenhouse, 1996). Left untreated, it causes pelvic inflammatory disease, ectopic pregnancies and infertility as well as a myriad of other complaints, including dyspareunia, dysuria, postcoital and intermenstrual bleeding, menorrhagia, dysmenorrhoea and lower abdominal pain.

Chlamydia trachomatis is the most common curable sexually-transmitted infection (STI) in the UK (Greenhouse, 1996). Left untreated, it causes pelvic inflammatory disease, ectopic pregnancies and infertility as well as a myriad of other complaints, including dyspareunia, dysuria, postcoital and intermenstrual bleeding, menorrhagia, dysmenorrhoea and lower abdominal pain.

Although the infection is often asymptomatic in its initial stages, any symptoms that do appear are frequently so diverse that tests for STIs, and in particular for chlamydia, may not be considered in the initial process of diagnosis. Any suggestion by a health care worker that the patient may have contracted an STI risks being met with shock, misunderstanding and denial. So if it cannot be diagnosed without specific microbiological tests, how much more difficult is chlamydia to spot when patients are reluctant to admit any risk?

Prevalence of Chlamydia trachomatis is difficult to estimate and varies between 2-23%, depending on the population tested (Stokes, 1997). The peak rate among groups tested for infection is achieved in under-20-year-olds seeking termination of pregnancy. However, it is perhaps unsurprising to find such a peak when a 'captured' population is being tested.

Those young women undergoing termination are the unfortunate ones who failed to use any method of contraception and whose unprotected sexual intercourse led to pregnancy. However, it is likely that a similar proportion of women in unstable relationships who, while using contraception, do not use a barrier method are at equally high risk of contracting chlamydia. Each act of unprotected sexual intercourse with an infected partner carries a 70% chance of passing on the disease (Social Exclusion Unit, 1999).

Young women may be seen to be at greatest risk of the more serious effects associated with the infection. Chlamydia trachomatis can have severe implications for future fertility and well-being, and the emotional costs of infertility, ectopic pregnancy and miscarriage are immeasurable.

The relevance of routine health screening for this at-risk population must be weighed against the cost of treatment for infertility and associated sequelae. Howell (1998) reported on a screening programme of nearly 8,000 asymptomatic women and demonstrated the cost-effectiveness of universal screening within a specific age group. Having determined the necessity to screen, and with all the right protocols and procedures in place, there is just one more hurdle to overcome.

A major problem associated with any chlamydia screening programme is the reluctance of young women to undergo vaginal examination. Screening implies a direct connection between sexual activity and infection, which incurs connotations of infidelity, blame and guilt.

It is essential that patients are not made to feel any shame in admitting to having exposed themselves to the risk of infection (Duncan and Hart, 1999). Sensitive counselling, given in a safe and trusting environment, will assist patients in making informed decisions about their exposure to risk and need for screening.

Southend-on-Sea Family Planning Services is a full-time clinic based close to a busy shopping centre with 25,000 patient contacts per year. These are mainly female, and 60% are under 25 years old. With the support and assistance of the local area health authority, a chlamydia screening programme has been running at the clinic for nearly three years, during which time 1,412 female patients have been screened.

All sexually active female patients aged 25 and under were counselled about chlamydia and offered opportunistic testing (Fig 1). Positive results have been obtained in girls aged from 13-25 (Fig 2).

The prevalence of chlamydia among the tested population as a whole was 9% (126 women). However, this was higher in the younger age groups - of the 24 under-15-year-olds tested, four (16.66%) were infected, as were 10% of 15-19-year-olds (Fig 3).

The nurses at this clinic have worked hard to ensure that all patients who fall within the criteria of the screening programme (Box 1) are made aware of the risk of infection and offered a test. The pivotal task in achieving this aim has been to raise awareness about chlamydia, and to this end a number of initiatives have been started:

- A permanent display informing patients about chlamydia has been established in a prominent position in the clinic;

- Chlamydia information leaflets are placed on the waiting room chairs every day;

- Family planning nurses utilise their regular visits to local schools as part of a cytology screening information programme to raise awareness of chlamydia;

- A local school has been involved in a poster campaign.

These initiatives ensure that before the nurse has the opportunity to talk about chlamydia in the security of the private counselling room the majority of patients are already familiar with the risks, even if only at a vague level, and are receptive to further discussion. The subject is discussed with all under-25-year-old patients, including those who are not currently at risk. The test is offered either at the time of counselling or at a time more suitable for the patient.

While some young women may initially deny being at any risk, further discussion about their present and previous partners and relationships may help them to re-evaluate their own level of risk. Many agree to return at a later date, although as many as 40% of tests are conducted at the time of initial counselling. A further 20% return within four weeks of counselling.

It is recognised that a number of patients fail to return for testing, and nurses will discuss this with them at their next visit. Certainly there are patients who, having initially refused a screen, return some weeks or months later when perception of their own risk has altered.

An essential tool in the fight to reduce the prevalence of chlamydia in the community is the ability to offer immediate treatment, further testing and partner notification. To this end the local genito-urinary medicine clinic at Southend General Hospital works in close liaison with the family planning services to offer appointments within 24 hours, where possible, to patients with a positive chlamydia result. Very few patients are then lost to follow-up.

Of those patients who have stated that they did not wish to be tested, 79% felt they were not at risk. This group was predominantly in their first sexual relationship with a partner in the same situation, or had previously been tested at other centres and had not exposed themselves to further risk. Only very few (10% of all refusals) declined testing due to embarrassment or fear of a vaginal examination.

The family planning clinic is now finding that some patients are returning for a repeat chlamydia swab following the break-up of an existing relationship. The stigmatisation that often occurs with STIs appears to be breaking down and is no longer such a barrier to testing. The easy approach with which chlamydia is discussed and highlighted in the clinic has helped in the removal of such barriers.

It is widely recognised that the prevalence of chlamydia, along with other infections such as gonorrhoea and trichomonas, is increasing. The government's long-awaited National Strategy for Sexual Health and HIV (Department of Health, 2001) acknowledges the need to integrate family planning services within the wider remit of sexual health screening. It is to be hoped that the success of Southend's chlamydia screening programme has shown that family planning patients will readily accept such services.

Family planning nurses are ideally placed to fulfil the needs of the 'one-stop shop' requirement for sexual health services, under the auspices of the new strategy.

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