BASHH 2009 Asymptomatic Screening Audit in UK GUM Clinics

1. BASHH 2009 Asymptomatic Screening Audit in UK GUM Clinics ~ Case Notes Audit ~

2. BASHH 2009 Asymptomatic Screening Audit • Audit methods • Results (selected) • Limitations • Conclusions • Recommendations for practice change 

3. Recommendations audited against • BASHH Clinical Effectiveness Group: Sexually Transmitted Infections: UK National Screening and Testing Guidelines August 2006* *http://www.bashh.org/guidelines

4. Asymptomatic case definition • No symptoms offered on presentation (either on a triage form, or similar form, or on direct questioning by a healthcare worker) • New or re-book

5. Methods • First 30 consecutive patients January to March 2009 • Questionnaire designed by NAG, available at: http://www.bashh.org/groups • Electronically data submission using Feedback Server software and downloaded for analysis using Microsoft Access and Excel. • Data collated and aggregated by • Clinics: regional aggregates • Regions: national aggregate

6. Results …

7. Main messages • HIV, syphilis, chlamydia – good testing performance against BASHH first line recommended tests • Gonorrhoea: good testing performance only when culture plus NAATs included • Throat and rectal gonorrhoea screening common practice for MSM • Especially when sexual history documented

8. Contribution of cases, N= 4428 • 4428 cases from 157 clinics (~60% of all GU Medicine clinics) • Regional contribution: 2-17%

9. Gender & sexual preference, N= 4428 • Men: 2297 (52%, 43–59%) • Heterosexual: 2078 (47%, 37–56%) • MSM: 219 (5%, 2–8%) • Women: 2131 (48%, 41–57%)

10. Results: specific infection screening in asymptomatic groups HIV & syphilis screening …

11. HIV screening in asymptomatic groups “All patients attending the GUM clinic should be offered an HIV test, according to the National Strategy for Sexual Health and HIV ” Testing uptake standard 60%

12. HIV testing in women (n=2131)

13. HIV testing in MSM (n=219)

14. Syphilis screening* in asymptomatic groups “Screening is recommended for all asymptomatic patients attending a UK GU clinic” *Any test for syphilis: EIA, TPPA, VDRL/RPR,TPHA

15. Chlamydia screening …

16. Chlamydial screening

17. Gonorrhoea screening …

18. MSM, n= 219 CEG test of choice: culture for invasive sampling * Recommended if urethral specimen not available

19. Heterosexual men, n=2078 CEG test of choice: culture for invasive sampling * Recommended if urethral specimen not available

20. Women, n=2131 CEG test of choice: culture for invasive sampling

21. Throat and rectal screening for gonorrhoea by culture

22. Asymptomatic MSM: rectal and throat gonorrhoea culture, n= 219

23. NAATs for gonorrhoea screening

24. Urine NAATs for Gc in MSM

25. Conclusions and recommendations

26. Limitations- not known: • Patient, clinician or systems preferences influencing choice of • Invasive/non-invasive sampling • NAATs/culture • Positive NAATs for gonorrhoea • Culture confirmation • Repeat testing with different NAAT target to avoid false positives

27. Main messages • HIV, syphilis, chlamydia – good testing performance against BASHH first line recommended tests • Gonorrhoea: good testing performance only when NAATs included • Urine GC NAATs: often used, including 45% MSM • Throat and rectal gonorrhoea screening common practice for MSM • Especially when sexual history documented

28. Suggested Areas for Practice Improvement/Interventions- 1 • Increased documentation of discussion about oral and anal sex • Recommended in the BASHH Guideline on sexual history taking • Identifies anatomical sites for sampling

29. Suggested Areas for Practice Improvement/Interventions- 2 • Culture needed in every clinic? • Regional strategies? … … balance NAATs with culture testing for gonorrhoea to monitor antibiotic sensitivity (Gonococcal Resistance to Antimicrobials Surveillance Programme)

30. Detailed data and PowerPoint presentation on: www.bashh.org/committees/nag/index.htm • Late 2010: DH-funded audit of BASHH STI Management Standards … the end

31. ACKNOWLEDGEMENTS The work done by all NHS staff who submitted data and supported the Audit is gratefully acknowledged. The work done by those running the pre-pilot and pilot phases is gratefully acknowledged. The work done by the Regional Chairs and staff in NHS Trusts/Clinics is gratefully acknowledged. Membership of National Audit Group, October 2008: Chris Carne (Chair), David Daniels (Vice-Chair), Hugo McClean (Hon Sec), Anatole Menon-Johansson (Director of Development), Raymond Maw (N.Ireland and BCCG chair), Ed Wilkins/Alison Rodger (BHIVA Representative), TC Harry (Anglia), Gail Crowe (Essex), Ravindra Gokhale (Merseyside), Ann Sullivan (N Thames), Eva Jungmann (N Thames), Sarup Tayal (Northern), Ashish Sukthankar (North-West), Adil Isaac (Oxford), Steve Baguley (Scotland), Arnold Fernandes (South-West), Cindy Sethi (SE Thames), Steven Estreich (SW Thames), Jyoti Dhar (Trent), Helen Bailey (Wales), Sarah McAndrew (Wales), Reena Mani (Wessex), Kaveh Manavi (West Midlands), Amy Tobin-Mammen (Yorkshire), Paul Bunting (Co-opted Member), Irene Vaughan (Co-opted Member), Mike Walzman (Co-opted Member),Nicola Low (Co-opted Member). The advice and support of Hilary Curtis in designing the on-line questionnaires and in collecting, processing and tabulating the audit data into a national aggregate and regional aggregates is gratefully acknowledged.