The Primary Care Consultation and Sexual Health

1. The Primary Care Consultation and Sexual Health

2. Aims of today • Why is it important? • Overcoming barriers • Assessing risk • Reducing risk • Scenarios

6. Which symptoms might be caused by a STI • Vaginal/urethral discharge • Dysuria • Abdominal pain • Conjunctivitis • lymphadenopathy • Pharyngitis • Weight loss • Post-coital bleeding • Uveitis • Seborrhoeic dermatitis • Arthritis • Aortic regurgitation • Diarrhoea • Pelvic pain • Genital ulcer • Flu-like illness

7. Which symptoms might have a cause other than a STI • Vaginal/urethral discharge • Dysuria • Abdominal pain • Conjunctivitis • lymphadenopathy • Pharyngitis • Weight loss • Post-coital bleeding • Uveitis • Seborrhoeic dermatitis • Arthritis • Aortic regurgitation • Diarrhoea • Pelvic pain • Genital ulcer • Flu-like illness

8. Beware! 50-80% chlamydia is assymptomatic

9. What are the risk factors for STIs • <25 • Single • 2 or more sexual partners in the last 6 months • No condoms • Sexual orientation • City dwellers • Ethnicity

10. How is Primary Care different from GUM? Not everyone is at risk of an STI Patients may not see themselves as being at risk Patients may not expect questions about sex They come with several unrelated problems

11. What are the barriers to taking a sexual health history • Patients accompanied • Under 16 • Patient may not want to talk about it. • Fear of inclusion on records • Fear of others seeing records • May not be on the patient’s agenda • Clinician anxiety or embarressment • It will take too long… • Patient doesn’t see themselves at risk

12. Why is it important? • Being assymptomatic doesn’t stop transmission • May not be recognised as STI if symptoms are mild or unrelated to the genital area • Untreated STI’s have serious consequences

13. When is it appropriate to talk about STI risk? • New patient registration • Contraception • Pre- IUD/IUS • Travel clinic • Any symptoms which are suggestive of an STI If we don’t ask, they won’t tell

14. What are your barriers to talking about sexual health in a consultation?

15. Principles of doing a sexual risk assessment

16. Who is at risk?

17. Youth • Sexual inexperience • Beliefs system • What patients believe about you • What you believe about patients • Time • Unsure what to say • ????

18. Reasons for doing a risk assessment • If no apparent risk • stops unnecessary tests • If at risk • increases positivity • More specific education • Repeat testing if new risk • good management of positive results

19. “so you’re in a stable relationship aren’t you?”

20. General • Be matter of fact • Practice some scripts • Consider the patient’s beliefs & barriers • Work with the patient so that decisions are collaberative • Counsel patients appropriately • Maintain confidentiality • Be non-judgmental • Seek their consent to explore furhter

21. Move to a shared understanding • Does the patient think they are at risk? • Do you think they are at risk

22. Raising the issue out of the blue In the symptomatic patient

23. An STI is one possible diagnosis of many Make it clear that you do not know if the patient is at risk until you have established their risk

24. “ sometimes people who present with symptoms like this may have a sexually transmitted infection. Would it be OK if I asked you a few questions to see if you might be at risk?”

25. Out of the blue - The assymptomatic patient

26. Depersonalise & routine • “ as part of our contraception checks, we normally ask patients if they might be at risk of a sexually transmitted infections so that we can offer appropriate testing. Would it be OK if I asked you a few questions to see if you are at risk?”

27. Share knowledge “As you’re probably aware, Chlamydia is a common sexually transmitted infection in people of your age. Would it be OK if I asked you a few questions to see if you might be at risk?”

28. Accompanied patients • 18 year old girl with her friend • 15 year old girl with her mother • 17 year old girl with mild learning difficulties with her mother

29. Accompanied patients “ I need to ask some quite sensitive questions which are easier if you are by yourself. Would it be OK if your friend/partner/spouse waited outside?”

30. Remember Not everyone is at risk…… …….but some are. We won’t know an individual’s risk if we don’t ask.

31. Partner history • Do you have a sexual partner at the moment? • Is that a man/woman/both? • How long have you been together? • Have you or your partner had any other partners in that time? • When was the last time you had sex?

32. HIV questions • Have you ever had a sexual partner who comes from another country? Which country? • Have you ever wondered if any partners were at risk of HIV?

33. Avoid apportioning blame “ if a result is positive, it doesn’t tell us where the infection came from – just that the infection is in the relationship. Many infections can cause no symptoms and you have both had previous partners, so all we can say is that at some point it has been introduced into the relationship.”

34. Condom use • Do you use a condom? • Do you always use a condom? • Have you ever had problems using condoms?

35. Don’t make assumptions May be appropriate to explore additional risks • sex with those overseas • internet contacts • overseas travel • ivdu • sex workers • Specific sexual practices

36. The infections

37. Chlamydia Women Men Symptoms >50% asymptomatic Urethral discharge Dysuria Testicular/epididymal pain Proctitis Signs Normal Urethral discharge Local complications eg epididymitis • Symptoms • 80% asymptomatic • PCB/IMB • Purulent vaginal discharge • Lower abdominal pain • Dysuria • Signs • Normal • Cervicitis, muco-purulent discharge • Local complications egBartholin’s cyst

38. Chlamydia testing • Nucleic acid amplification tests (NAAT) replacing PCR • Male • First void urine vs swab • Women • Self-taken lower vaginal swab or endocervical swab

39. Chlamydia treatment Recommended Alternative Pregnancy/breastfeeding Erythromycin 500mg for 14/7 Alternative Erythromycin 500mg qds 7 days Ofloxacin 200mg bd or 400mg od for 7 days • Azithromycin 1g stat (assess risk vs benefit if pregnancy possible) • Doxycycline 100mg bd for7 days (not if pregnant/breastfeeding)

40. Patient information • Chlamydia is sexually transmitted • Often assymptomatic, but left untreated has potentially serious complicaitns • Need to see and treat sexual partners • Abstain from intercourse, until completion of therapy or 7 days after azithromycin • Need to complete treatment • Advice on safer sexual practice

41. Do I need to retest? Not pregnant Routine test of cure are not indicated in >25’s Pregnant/ Rx with erythromycin 5 weeks after Rx or 6 weeks if given erythromycin Under 25’s

42. Gonorrhoea Men Women Symptoms Cervical infection assymptomatic – 50% vaginal discharge –50% lower abdo pain <25% Rectal infection- 80% assymptomatic Pharyngeal infeciton – 90% assymptomatic • Symptoms • Urethral infection-85% symptomatic within 10 days • Rectal infeciton – 80% assymptomatic • Pharyngeal infection – 90% assymptomatic

43. Men Women Cervicitis Mucoid -> purulent discharge Cervical excitation Signs PID Non genital signs • Mucoid-> purulent urethral discharge • Meatitis • Non- genital signs • eg rectal discharge, pharymgitis, • Disseminated infectino

44. Tests Men Self taken LVS for NAAT Endocervical swab – NAAT & culture • Urine • First pass urine for NAAT • Urethral swab

45. Treatmetn Onward referral to GUM

46. HIV Why screen? • 33% patients in Cumbria present late • Incidence rising in heterosexual population • HIV is a treatable disease • Early treatment improves length & quality of life • Reduction of onward transmission • Reduction in vertical transfer Medical benefits outweigh negatives eg life insurance

47. Approx third of HIV positive patients are unaware they are positvie Many are attending GP surgeries and not being offered appropriate tests

49. Window period to seroconversion • Modern tests will detect majority of infected individuals at one month • A negative result at 4 weeks post exposure is reassuring • Further test at 12 weeks

50. Common presentaitons • Sero-conversion • `50-80% of patients develop self-limiting flu-like illness, sometimes with a rash 2-4 weeks after infection HIV risk history approached sensitively may help identify those at greatest risk