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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

6.2 Sexually Transmissible Infections

Sexually transmissible infections (STIs) are frequently seen in general practice, especially chlamydia, which is typically asymptomatic.5,6 It is important to detect it early in order to prevent transmission to others and minimise potential complications, such as infertility. It may also be appropriate to screen for other STIs. The individual’s age, sexual behaviour and community HIV or STI prevalence all influence the level of risk, and should influence the choice of STI screening tests.

For additional resources specific to Aboriginal and Torres Strait Islander peoples, The Royal Australian College of General Practitioners’ (RACGP) National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (2nd edn)includes information about sexual health and blood-borne viruses.

Sexual health consultation

Many patients and doctors feel uncomfortable discussing sexual histories even when indicated or the patient is requesting STI testing. Taking a sexual history is an important part of the assessment and management of STIs, and it should not be a barrier to offering STI testing.7

A non-judgmental attitude and environment will facilitate disclosures on sexual matters.8 It is important to ask open-ended questions and to avoid assumptions about sexual orientation, by using the term ‘partner’. Gentle enquiry about recent sexual activity, gender, number of partners, contraception (including use of condoms), travel history, and immunisation status helps to inform decision making. Additionally, ask about the risk for blood-borne viruses (hepatitis B, C, and HIV), such as injecting drug use, tattooing and piercing. Investigations should be explained, and patients should be asked for consent before tests such as HIV or hepatitis C are ordered.

Contact tracing

Contact tracing is essential in reducing the transmission of STIs and HIV. It is the responsibility of the diagnosing clinician to facilitate the process of notifying current and past partners. This may be through a direct approach from the patient, their treating health professional, or by using online partner notification services available such as:

For more information and to determine ‘how far back to trace’, refer to the contact tracing manual at the Australasian Society of HIV, Viral Hepatitis and Sexual Health Medicine’s (ASHM) website or the Contact Tracing Tool for General Practitioners at NSW STI Programs Unit's website

For HIV contact tracing, seek assistance from local sexual health services.

In the case of a notifiable condition, the patient should be informed that case notification to public health authorities will occur. Notification should be made as set by the department of health in the relevant state or territory.

6.2.1 Chlamydia and other STIs

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 >80

More than 80% of chlamydia infections occur in people <29 years of age.9 Screening for chlamydia infection in all sexually active people up to 29 years of age is recommended because of increased prevalence and risk of complications.10 In asymptomatic, sexually active people up to 29 years of age, the overall absolute risk of infection is approximately 5% for chlamydia and 0.5% for gonorrhoea.

The ranked risk for specific infections per 100,000 in general population/Aboriginal and Torres Strait Islander populations:11

  • Chlamydia (371/1341)
  • Gonorrhoea (49/858)
  • Hepatitis B (23/50)
  • Syphilis (8/32)
  • HIV (4/6)

A large proportion of young people will attend primary care clinics each year, and this presents the opportunity to normalise sexual health care as part of usual general practice.10 Younger sexually active youths should not be excluded from case finding, or identifying any safety or abuse issues. This may involve a complete psychosocial (HE2ADS3)12 risk assessment as discussed in Table 3.2.

Women with untreated chlamydia infections have a 2–8% risk of infertility.13 Other STIs to consider screening for in higher risk individuals are gonorrhoea, HIV and syphilis.14 The risk for gonorrhoea, HIV and syphilis is low for heterosexuals in all major cities in Australia and New Zealand,15 but rates of gonorrhoea and syphilis are higher among MSM. The individual’s age and sexual habits, and community STI prevalence all influence the level of risk and should guide STI testing recommendations for patients (refer to Tables 6.2.1.1 and 6.2.1.2 for guidance).

MSM should be screened for gonorrhoea, chlamydia, syphilis and HIV every 12 months. Screening should be performed more often if they have multiple sexual contacts. Most MSM with STIs have no symptoms.16

Aboriginal and Torres Strait Islander peoples are at higher risk and should also be screened for gonorrhoea, chlamydia, syphilis and HIV.

Screening for hepatitis C should be provided if the patient is HIV positive or there is a history of injecting drug use, as this increases the risk of transmission.16

All pregnant women should be screened for hepatitis B, C, HIV and syphilis.14,17,18 Consider screening pregnant women up to 29 years of age for chlamydia (and also gonorrhoea, if the patient is at high risk).17–20

Table 6.2.1.1. Sexually transmissible infections: Identifying risks
Risk assessment of asymptomatic sexually active personWhat should be done?How often?
Low–average risk:
  • Heterosexual asymptomatic up to 29 years of age requesting sexually transmissible infection (STI) check up
Urine, cervical or genital swab polymerase chain reaction (PCR; or self-collected) for chlamydia5

Consider other infections based on risk assessment
Opportunistically if indicated (evidence is unclear on testing interval)
Medium–high risk:
  • <20 years of age
  • Rural and remote
As above 6,10,11,21–26

Consider other infections, particularly gonorrhoea and syphilis, based on risk assessment
Opportunistically if indicated (evidence is unclear on testing interval)
Higher risk:
  • Aboriginal or Torres Strait Islander peoples
Testing for chlamydia, gonorrhoea, syphilis27

Serology for human immunodeficiency virus (HIV), syphilis and, if the person is not vaccinated or immune, hepatitis A and B (III)

Offer hepatitis A and B vaccination (III, B)
Every 12 months (evidence is unclear on testing interval)
Other higher risk:
  • People who inject drugs
  • Sex workers
Testing for chlamydia, gonorrhoea, syphilis; Serology for HIV, syphilis; if the person is not vaccinated or immune, hepatitis A and B

Offer hepatitis A and B vaccination (III, B)

Hepatitis C testing if the patient injects drugs
Every 12 months (evidence is unclear on testing interval)
Highest risk:
  • Asymptomatic men who have sex with men
  • Highest risk in those who:
    • have unprotected anal sex
    • had >10 partners in past six months
    • participate in group sex or use recreational drugs during sex
Urine, throat and rectal swab for chlamydia PCR 5,16,28

Throat and rectal swab for gonorrhoea PCR (III, B)

Serology for HIV, syphilis and, if the person is not vaccinated or immune, hepatitis A and B

Offer hepatitis A and B vaccinations (III, B)
Every 12 months and three to six monthly in higher risk men
Sexual contacts from the last six months of women and men with an STI

For how far back to trace, refer to Contact Tracing Tool for General Practice
Test and treat contacts presumptively (II, A)29–32

Consider other infections based on risk assessment such as gonorrhoea, hepatitis B (if not vaccinated), syphilis and HIV (III, B)
If chlamydia infection found (and treated), repeating testing to check for re-infection after 3–12 months may be appropriate
HIV, human immunodeficiency virus; PCR, polymerase chain reaction; STI, sexually transmissible infection
Table 6.2.1.2. Tests to detect sexually transmissible infections
TestTechnique
Nucleic acid amplification test most commonly by polymerase chain reaction (PCR) The first 20 mL of urine passed at any time of day, and at least 20 minutes since last voiding33

PCR testing can be performed on urine, throat, endocervix rectum, or vagina (whichever are indicated) 5,15,30,34
Gonorrhoea microscopy, culture and sensitivity (MCS) If the suspected clinical diagnosis is gonorrhoea, an MCS is required to guide antibiotic treatment 11
MCS, microscopy, culture and sensitivity; PCR, polymerase chain reaction

Implementation

Chlamydia is the most common and curable STI in Australia. Notification rates per 100,000 increased from 35.4 in 1993 to 363 in 2011, and has been steady since; 78% of those infected are aged 15–29 years.11 Young Aboriginal and Torres Strait Islander peoples have higher infection rates especially in regional and remote areas, with a substantially increased risk of chlamydia, gonorrhoea and syphilis.10

Screening sexually active women <25 years of age for chlamydia on an annual basis has been shown to halve the infection and complication rates.11,13,35

Treatment of partners and contact tracing

All partners of those infected should be tested and treated presumptively. A systematic review has shown that providing patient-delivered partner therapy to index cases is more effective in reducing infection rates than paper-based methods of contact tracing.36 There is no single optimal strategy for contact tracing. Getting assistance from the local sexual health services is recommended for HIV and syphilis because it leads to more contacts being tested and treated.35 Referral to sexual health services should be considered for problematic or repeated infections.37

It is important to ensure current sexual partners are treated simultaneously. Untreated pregnant women infected with chlamydia have a 20–50% chance of infecting their infant at delivery.38

References

  1. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine. HIV, viral hepatitis and STIs: A guide for primary care. Sydney: ASHM, 2014.
  2. Kong FY, Guy RJ, Hocking JS, et al. Australian general practitioner chlamydia testing rates among young people. Med J Aust 2011;194(5):249–52.
  3. Pavlin NL, Parker R, Fairley CK, Gunn JM, Hocking J. Take the sex out of STI screening! Views of young women on implementing chlamydia screening in general practice. BMC Infect Dis 2008;8:62.
  4. Preswell N, Barton D. Taking a sexual history. Aust Fam Physician 2000;29(5):533–39.
  5. Department of Health. Third national sexually transmissible infections strategy 2014–2017. Canberra: DoH, 2014. Available at www.health.gov.au/internet/main/publishing.nsf/Content/ohp-bbvs-sti [Accessed 23 May 2016].
  6. Guy RJ, Ali H, Liu B, Hocking J, Donovan B, Kaldor J. Genital chlamydia infection in young people: A review of the evidence. Sydney: The Kirby Institute, 2011.
  7. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report 2015. Sydney: The Kirby Institute, 2015.
  8. Goldenring J, Rosen D. Getting into adolescent heads: An essential update. Contemp Pediatrics 2004;21(64):64–90.
  9. Hocking J, Fairley C. Need for screening for genital chlamydia trachomatis infection in Australia. Aust N Z J Public Health 2003;27(1):80–81.
  10. Meyers D, Wolff T, Gregory K, Marion L. USPSTF recommendations for STI screening. Am Fam Physician 2008;77(6):819–24.
  11. Cook RL, Hutchison SL, Ostergaard L. Systematic review: Noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005;142(11):914–25.
  12. Templeton DJ, Read P, Varma R, Bourne C. Australian sexually transmissible infection and HIV testing guidelines for asymptomatic men who have sex with men 2014: A review of the evidence. Sex Health 2014;11(3):217–29.
  13. Australian Health Ministers’ Advisory Council. Clinical practice guidelines: Antenatal care – Module II. Canberra: AHMAC, 2014.
  14. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Routine antenatal assessment in the absence of pregnancy complications. East Melbourne, Vic: RANZCOG, 2016. Available at www.ranzcog.edu.au/college-statements-guidelines.html#obstetrics [Accessed 28 April 2016].
  15. Cheney K, Wray L. Chlamydia and associated factors in an under 20s antenatal population. Aust NZ J Obstet Gynaecol 2008;48(1):40–43.
  16. Chen MY, Fairley CK, De Guingand D, et al. Screening pregnant women for chlamydia: What are the predictors of infection? Sex Transm Infect 2009;85(1):31–35.
  17. Scholes D, Stergachis A, Heidrich FE, Andrilla H. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Eng J Med 1996;334(21):1362–66.
  18. Queensland Health. Indigenous sexual health service report for Brisbane Southside. Brisbane: Communicable Disease Unit, 2004.
  19. Low N, McCarthy A, Macleod J, Salisbury C. Epidemiological, social, diagnostic and economic evaluation of population screening for genital chlamydial infection. Health Technol Assess 2007;11(8):1–165.
  20. Heal C, Jones B, Veitch C, Lamb S, Hodgens S. Screening for chlamydia in general practice. Aust Fam Physician 2002;31(8):779–82.
  21. Hayman N. Chlamydia PCR screening in an Indigenous health general practice clinic in Brisbane 2002–3. Brisbane, 2004.
  22. Uddin RN, Ryder N, McNulty AM, Wray L, Donovan B. Trichomonas vaginalis infection among women in a low prevalence setting. Sex Health 2011;8(1):65–68.
  23. The Kirby Institute. Bloodborne viral and sexually transmitted infections in Aboriginal and Torres Strait Islander people: Surveillance and evaluation report. Sydney: The Kirby Institute, 2014.
  24. Whiley DM, Garland SM, Harnett G, et al. Exploring ‘best practice’ for nucleic acid detection of Neisseria gonorrhoeae. Sex Health 2008;5(1):17–23.
  25. Whittington WL, Kent C, Kissinger P, Oh MK. Determinants of persistent and recurrent chlamydia trachomatis infection in young women: Results of a multicenter cohort study. Sex Transm Dis 2001;28(2):117–23.
  26. Orr DP, Johnston K, Brizendine E, Katz B. Subsequent sexually transmitted infection in urban adolescents and young adults. Arch Pediatr Adolesc Med 2001;155(8):947–53.
  27. Guy R, Wand H, Franklin N, et al. Re-testing for chlamydia at sexual health services in Australia, 2004–08. Sex Health 2011;8(2):242–47.
  28. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. MMWR 2006;55:38–40.
  29. Kwan B, Ryder N, Knight V, et al. Sensitivity of 20-minute voiding intervals in men testing for Chlamydia trachomatis. Sex Transm Dis 2012;39(5):405–06.
  30. Watson E, Templeton A, Russell I, Paavonen J. The accuracy and efficacy of screening tests for Chlamydia trachomatis: A systematic review. J Med Microbiol 2002;51(12):1021–31.
  31. Ferreira A, Young T, Mathews C, Zunza M, Low N. Strategies for partner notification for sexually transmitted infections, including HIV. Cochrane Database Syst Rev 2013;10:CD002843.
  32. Trelle S, Shang A, Nartey L, Cassel J, Low N. Improved effectiveness of partner notification for patients with sexually transmitted infections: Systematic review. BMJ 2007;334(7589):354.
  33. Burnet Insitute. Partner notification of sexually transmitted infections in New South Wales: An informed literature review. Melbourne: Centre for Population Health, 2010. Available at http://stipu.nsw.gov.au/wp-content/uploads/NSW_STI_PN_PDF.pdf [Accessed 28 January 2016].
  34. Honey E, Augood C, Templeton A, et al. Cost effectiveness of screening for Chlamydia trachomatis: A review of published studies. Sex Transm Infect 2002;78(6):406–12.
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