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Risk assessment, screening and the subsequent management of STIs

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Robert Irwin, BA (Hons), MSc, RN.

Senior Charge Nurse, HIV and Sexual Health Team, Kennet and North Wiltshire Primary Care Trust, Chippenham, Wiltshire

This is a two-part series comprising: - May 2003: Reducing the transmission of STIs. - July 2003: Treatments and screening for STIs and problems for health-care staff.

This is a two-part series comprising: - May 2003: Reducing the transmission of STIs. - July 2003: Treatments and screening for STIs and problems for health-care staff.

Many sexually transmitted infections (STIs) do not cause any external symptoms in their initial stages, making it difficult for health professionals to identify patients who may have an STI. Even when patients present with symptoms suggestive of an STI some form of risk assessment will be necessary.

Risk assessment
The information required to assess a patient's risk of STIs is listed in Box 1. For those presenting with urogenital symptoms suggestive of an STI - or conditions that may be associated with STIs such as pelvic pain (pelvic inflammatory disease), unilateral testicular pain (epididymitis) or joint pain (Reiter's syndrome or sexually acquired reactive arthritis) - such an assessment can provide information that will assist diagnosis and enable management to be adjusted according to the probability of symptoms being caused by an STI.

This may be especially important where patients present to practitioners in primary care. Matthews (1998) notes: 'The genitourinary model of risk of STI ('everyone is at risk') is extremely useful but perhaps works a little less well for primary care. Some of our patients are indeed not at risk of having an STI, and their menorrhagia or dysuria or discharge must be due to something else, simply because they have never been sexually active.'

In addition to assisting the clinician to arrive at a more accurate diagnosis of urogenital or anogenital symptoms, risk assessment can offer a guide for selective screening of asymptomatic patients.

Curtis and Holmes (1999) state that STI/HIV risk assessment should be part of routine screening in most clinical settings. However, it is crucial for primary care practitioners undertaking a risk assessment for STI in asymptomatic patients to exercise considerable sensitivity and skill (Barton and Jewitt, 1995). This is essential since, although patients attending with urogenital symptoms may anticipate being questioned about their sexual history, those attending for other reasons are unlikely to consider the possibility (Bor and Watts, 1993). Furthermore, including an STI/HIV risk assessment as part of health screening for all patients in primary care could be seen not only to be a further example of the increasing medicalisation of sexual behaviour (Hart and Wellings, 2002), but also an invasion of privacy.

Risk assessment, even in a genitourinary medicine (GUM) clinic is complicated by the fact that many patients, in giving details of their sexual history, will not only withhold information (Bilney and d'Ardenne, 2001) but also modify it depending on the listener. Perceived social desirability and concern about confidentiality may all have a bearing on what is disclosed. Despite the limitations, taking a sexual history enables health education to be tailored to individual need, facilitates a better informed diagnosis and allows screening for STIs to be discussed with those who might be at risk.

While the health benefits associated with early detection and treatment of STI are considerable, the costs of screening in terms of adverse effects on a patient's well-being are less easily quantifiable (Duncan and Hart, 1999). Reaction to such a diagnosis may range from a sense of inconvenience to extreme distress. Green (2002) suggests that high levels of anxiety are common. The level of distress experienced by an individual will be influenced by a number of factors including:

- The potential long-term morbidity associated with an infection

- Any pain or disruption to lifestyle caused by the infection

- Whether the condition is disfiguring (such as presence of genital warts) or incurable (HIV)

- The person's previous psychological well-being

- Whether the results are unexpected.

Duncan et al (2001), in reporting the results of a qualitative study of 17 women recently diagnosed with chlamydia, observe: 'Most women had not previously perceived sexually transmitted infections as personally relevant; this was a function of stereotypical beliefs about who was 'at risk' of sexually transmitted infection. These beliefs were pervasive and negatively affected reactions to diagnosis, and produced anxiety about disclosure of the condition to others (particularly sexual partners) and future reproductive morbidity. This anxiety, given the uncertain natural history of chlamydia, may prove difficult to dispel.'

Uncertainty surrounding the natural course of chlamydial infections, and the concurrent possibility of having acquired the infection from a previous partner, can sometimes mitigate the threat to an individual's current relationship. However, Duncan et al (2001) note that, while uncertainty about the duration of infection may reduce anxiety about a partner's fidelity, it can also increase concern about possible long-term reproductive morbidity. In conclusion, they cite three requirements for a chlamydia screening programme that seem applicable to screening for STIs in general. These are the need to:

- Provide information that normalises and destigmatises STIs and positively promotes genitourinary medicine services

- Offer support services to facilitate partner notification

- Issue staff undertaking screening with guidance on the advice to offer patients diagnosed with infections where uncertainty exists about possible long-term morbidity.

An evaluation by Pimenta et al (2003a) of a pilot screening programme that offered opportunistic screening for chlamydia to women (and some men) aged 16 to 24 years old at general practices and other health settings in Portsmouth and the Wirral revealed a high uptake among the estimated sexually active population, indicating that opportunistic screening for chlamydia is acceptable to many. (Urine samples were used, so no invasive procedures were required.)

The prevalence of genital chlamydial infection was found to be 9.8% in Portsmouth and 11.2% in the Wirral. The prevalence was higher among those attending termination of pregnancy clinics and GUM clinics compared with those attending family planning clinics and general practice (Pimenta et al, 2003b). As a consequence of the results of this study, a phased national roll-out of chlamydia screening has been proposed in the National Strategy for Sexual Health and HIV for England, and the chlamydia screening pilot is being extended to a further eight centres (Department of Health, 2001; 2002).

Practitioners in clinical areas where screening and/or treatment for STIs are not offered will need to refer patients to a GUM department or an integrated sexual health clinic. They need to be aware of the evidence indicating that many people delay seeking treatment at a GUM clinic, often for a considerable time (Pitts et al, 2000). The perceived stigma associated with STIs can act as a barrier to attending a clinic (Scoular et al, 2001); the attitude to STIs of health professionals working outside GUM settings may also reinforce this (McClean et al, 1995). None the less, the number of attendances at GUM clinics has doubled in the past decade. This, however, has had the effect of making to more difficult to get an appointment, even for patients with acute severe symptoms, posing a new obstacle to patients promptly accessing such services (Foley et al, 2001).

Screening for STIs and HIV has been advocated by health professionals on the assumption that the experience of screening per se (and the subsequent results of tests performed) will lead to changes in so-called risky behaviours. Although there is evidence to suggest that HIV testing and counselling motivates behaviour changes in some, this is not the case generally (Wolitski et al, 1997).

A meta-analysis of studies examining the effects of HIV counselling and testing on sexual risk behaviours concluded that, while the incidence of subsequently diagnosed STIs fell among individuals with HIV, it increased among both those who did not have HIV and those who were not tested (Weinhardt et al, 1999).

Conversely, it would be incorrect to assume that, because someone has HIV, he or she is not at risk of acquiring/transmitting an STI. Research in the USA suggests that since the advent of highly active antiretroviral therapy, the incidence of STIs among people on combination anti-HIV therapy has risen (Scheer et al, 2001). Research in the UK, however, has shown that behavioural and clinical risk factors for HIV transmission are consistently lower in men with HIV on HAART therapy compared with those who are not (Stephenson et al, 2003).

Some patients may request screening for STI and/or HIV as a prevention strategy when they enter a new sexual relationship. In such instances, a number of issues will need to be clarified:

- Whether both partners have had previous sexual relationships, in which case both will need to undergo screening tests

- No medical screening test has both a 100% sensitivity and a 100% specificity, so the possibility of false negative results needs to be considered. (The three-month 'window period' for antibody production must be discussed with all patients requesting HIV testing)

- Testing negative for STIs offers conditional reassurance only (for example, negative results are potentially invalidated if one, or both, partners has sex with someone else).

The use of STI screening within this context is therefore a risk-reduction rather than a risk-elimination strategy. Making patients aware of the health benefits of screening and facilitating access to such tests is an important aspect of the nurse's role in controlling STIs.

The diagnosis of an STI/STIs can cause considerable distress, and the listening and supportive skills of practitioners are crucial (Nelson, 1999; Irwin, 2002). For patients with bacterial STIs, compliance with treatment may be improved if there is a positive professional relationship between practitioner and patient. It is essential that patients undergoing treatment for conditions such as chlamydia, gonorrhoea, non-specific urethritis, Trichomonas vaginalis and syphilis are provided with clear verbal and written information on their management.

For bacterial STIs (Box 2), treatment of a patient's current sexual partner(s) is essential. Without this, the patient is likely to be reinfected as soon as he or she resumes sexual intercourse following treatment. As a result, the epidemiological treatment of partners of patients diagnosed with chlamydia and gonorrhoea is recommended even if the results of a partner's screening tests are negative.

Other factors to consider in treating bacterial STIs are the efficacy of various antimicrobial therapies, patient adherence to treatment, and follow-up. This offers the chance to assess the efficacy of treatment, exclude the possibility of reinfection, pursue follow-up partner notification, reinforce health education messages and reassure the patient.

Partner notification
Partner notification is the process of contacting the sexual partners of patients diagnosed with an STI, and advising them to attend for screening and treatment. Prompt identification, education and treatment of those exposed to infection(s) helps to:

- Break the chain of infection by limiting the number of asymptomatic but infectious people in the community

- Prevent complications of untreated infections

- Prevent reinfection of the index patient (the person initially identified as having the infection), in cases where an STI is bacterial in origin.

There are three main methods of partner notification:

- Index referral: this is where the index patients agree to notify sexual partners themselves

- Provider referral: this occurs when a health professional agrees to notify index patients' partners on their behalf

- Contract (conditional) referral: this occurs when the index patient agrees to try to notify partners within an agreed period of time. If they fail to do so, a professional does it on their behalf.

Index referral is the most common form of partner notification. In GUM clinics, this process often involves issuing contact slips. These contain the index patient's reference number, the date of attendance and diagnosis (in the form of a Department of Health code), as well as details about the issuing clinic. The index patient is asked to pass these slips to their sexual contacts. If partners attend a GUM clinic, similar details are recorded on the reverse of the slip and it is returned to the issuing clinic, enabling cross-referencing and verification of partner notification.

The advantage of this system is that it allows the diagnosis of the index patient to remain confidential while enabling the doctor to screen and treat the contact appropriately. A potential difficulty of using a system of codes, however, arises when an index patient's contacts prefer to see their own GPs for screening and treatment. Although the diagnoses indicated by each code is known nationally to staff in GUM clinics, it is not generally known to health professionals in primary care.

As to whether partner notification is an effective intervention, the evidence from published studies is generally supportive but mixed (Oxman et al, 1994; Cowan et al, 1996; Rothenberg and Potterat, 1999; Mathews, et al, 2001). Cowan et al (1996) note that partner notification is a relatively ineffective means of disease control in cases where sex with anonymous partners is common or where there is likely to be a considerable delay before sexual contacts can be traced.

Partner notification for STI began in an era when most known sexual infections were bacterial; the past three decades, however, have seen the emergence of viral STIs, for which there is no cure. Cowan et al (1996) suggest that 'from an epidemiological perspective, partner notification for viral STDs including HIV is only worthwhile if people who become aware of their infectivity modify their behaviour to reduce the risk of further disease transmission'.

For those with a viral infection discovering their diagnosis sooner rather than later has several advantages. Steps to reduce the risk of transmission to sexual partners and vertically to their children can be taken earlier, and more informed choices can be made about interventions to protect their health. A further benefit of partner notification for the contacts of viral STIs is that they can be offered screening for bacterial sexual infections, which may also pose a risk. However, the negative aspects of being diagnosed with an infection for which there is no cure, such as a viral STI or HIV, can prompt reluctance for patients to notify partners (Cowan et al., 1996; Chippindale, 2002).

Partner notification can also have a down side, such as the risk of relationship conflict and domestic violence. Although protecting the confidentiality of the index patient is central to partner notification strategies, in practice, if the contact has had only one partner, confidentiality is impossible (Cowan et al, 1996). Chippindale (2002) recommends providing psychological services for couples with adjustment issues, relationship difficulties or sexual problems following a diagnosis.

The majority of partner notification in the UK is done by health advisers (sometimes referred to as contact tracers), who tend to be based in GUM clinics. At present, many patients diagnosed with STIs in general practice are referred to GUM clinics to address the issue of partner notification. For a number of reasons, people may be reluctant to attend such a clinic and practitioners in primary care need to address this at the time of referral. The recent development of posts such as 'outreach health advisers' (Jones et al, 2002) may assist practitioners in facilitating partner notification.

Working to reduce the spread of STIs is an important aspect of promoting individual and public health. Practitioners working outside GUM services are presented with a number of challenges. These range from bringing up the issue of STI risk with patients to facilitating partner notification. Strategies to control the spread of STIs invariably pose dilemmas for all clinicians when their duty of care to the individual comes into conflict with the requirement to protect public health.

These problems can be difficult to resolve since the strategies used to control STIs can have adverse as well as beneficial effects. The absence of a systematic evidence base to support many commonly used interventions further compounds the situation. The fact that interventions to reduce the spread of STIs can cause harm as well as do good must be kept in mind by all practitioners working in sexual health care.

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