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Clinical guidelines

Guidelines for preventive activities in general practice 8th edition

6.2 STIs

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

Sexual health consultation

Many patients and doctors do not like discussing sexual histories even when the patient is requesting STI testing, or it is indicated. While taking a sexual history is an important part of the assessment and management of STIs, it should not be a barrier to offering STI testing. The patient may not disclose the truth to avoid embarrassment.201

A non-judgemental attitude and environment will maximise patient disclosures on sexual matters.202 It is important to ask open questions and to avoid terms that make assumptions about sexual behaviour or orientation (e.g. by using the term ‘partner’). Issues to cover include current sexual activity, gender and number of partners, contraception (including use of condoms), immunisation status and other risk factors for blood-borne viruses (such as injecting drug use, tattooing and piercing). Investigations should be explained, and patients should be counselled and asked for consent before ordering tests such as HIV or hepatitis C.

Contact tracing is an important part of the management of most STIs, and it is the responsibility of the diagnosing clinician to facilitate the process of notifying current and past partners. This may be by a direct approach from the patient or their treating health professional, or by using online partner notification services such as:

For more information and to determine ‘how far back to trace’ see the contact tracing manual at http://ctm.ashm.org.au/ or contact tracing tool at www.stipu.nsw.gov.au/content/ Document/GP%20Contact%20Tracing%20Tool.pdf

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 prescribed by the department of health in your 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

Screening for chlamydia infection in all sexually active people aged 15–29 years is recommended because of increased prevalence and risk of complications.203

Younger sexually active youth should not be excluded from case finding, or identifying any safety or abuse issues.

Women with untreated chlamydia infections have a 2–8% risk of infertility.204 Other STIs to consider screening for in higher risk individuals are gonorrhoea, HIV and syphilis.205 The risk for gonorrhoea, HIV and syphilis is low for heterosexuals in all major cities in Australia and New Zealand206 but rates of gonorrhoea and syphilis may be higher in remote community settings. The individual’s age and sexual behaviour and community STI prevalence influence the level of risk and should guide STI testing recommendations for patients. (Please refer to tables for guidance.)

Men who have sex with men (MSM) should be screened for gonorrhoea, chlamydia, syphilis and HIV every 12 months. Men who have multiple sexual contacts should be screened more often. Most MSM with STIs have no symptoms.207 Screening for hepatitis C should be provided if the patient is HIV positive or there is a history of injecting drug use.

There is good evidence that all pregnant women at risk should be screened for hepatitis B, HIV and syphilis;205 screen for chlamydia and possibly gonorrhoea if the patient is considered to be particularly at risk.208,209

Table 6.2.1.1 STIs: identifying risks
Who is at higher risk of infection and complications?What should be done?How often?
High-risk asymptomatic
  • All sexually active young people aged 15–29 years, particularly if:
    • under age 20 years
    • Aboriginal or Torres Strait Islander
    • inconsistent or no condom usage
    • recent change in sexual partner
Urine or genital swab for chlamydia (II, A)
Consider other infections based on risk assessment such as gonorrhoea, hepatitis B, syphilis and HIV
Consider trichomonas in remote communities (III)
Every 12 months203,210–215
A good opportunity is at same time as Pap test or presentation for other reasons216
Asymptomatic men who have sex with men
  • Higher risk in those who:217
    • have unprotected anal sex
    • have had >10 partners in past 6 months
    • participate in group sex or use recreational drugs during sex
Urine and rectal swab for chlamydia polymerase chain reaction (PCR)
Throat and rectal swab for gonorrhoea PCR (III, B)
Serology for HIV, syphilis and hepatitis A and B serology if not vaccinated or immune
Also offer hepatitis A and B vaccination (III,B)
Every 12 months and 3–6 monthly in higher risk men217, 218, 219
Sexual contacts from the last 6 months of infected women and men
For how far back to trace, see www.stipu.nsw.gov.au/content/Document/ GP%20Contact%20Tracing%20Tool.pdf
Test and treat contacts presumptively (II,A)
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 appropriate220223
Low risk heterosexual asymptomatic requesting ‘STI check-up’ Urine PCR or genital swab for chlamydia, serology for hepatitis B (if not vaccinated or immune), syphilis and HIV (III, B)219
Table 6.2.1.2 Tests to detect STIs
TestTechniqueSite
Nucleic acid amplification test (NAAT) most commonly by PCR
  • Should be (20 mL) first void urine (passed at least 1 hour after last having urinated (i.e. not midstream) (I,B)
  • PCR endocervical or vaginal swab (patient can self-collect) also possible in females (I,B)
    This technique has also been validated for anal or throat swabs:
  • NAATs are highly sensitive and specific for chlamydia and gonorrhoea from all specimens. False positive gonorrhoea results can occur, especially if testing low-risk individuals. However, laboratories usually perform supplemental assays to confirm results for gonorrhoea.
Urine, endocervix or vagina206,222,224,219
Gonorrhoea microscopy, culture and sensitivity (MCS)
  • Rectal swab should be inserted 3 cm into anus and rotated225
  • MCS is of use to guide treatment where resistance to antibiotics is a problem
 

Implementation

Chlamydia is the most common and curable STI in Australia. Notification rates per 100 000 have increased from 35.4 in 1993 to 319 in 2010, mostly in those aged 15–29 years.226 Estimated infection rates of the sexually active population in this age group vary from 4–12%. Young Aboriginal and Torres Strait Islander peoples have the highest infection rates, which are 12–34% in some locations. There is also an increased risk of gonorrhoea and syphilis among Aboriginal and Torres Strait Islander peoples.

Screening of sexually active women under age 25 years for chlamydia on an annual basis has been shown to halve the infection and complication rates204,227 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.228 It is important to ensure current sexual partners are treated simultaneously. Referral to a sexual health clinic may provide improved contact tracing and should be considered for problematic repeated infections.229

Untreated pregnant women infected with chlamydia have a 20–50% chance of infecting their infant at delivery.230

References

  1. 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
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  3. 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, University of New South Wales, 2011
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  10. Kong FY, Guy RJ, Hocking JS, Merritt T, Pirotta M, Heal C, et al. Australian general practitioner chlamydia testing rates among young people. Med J Aust 2011;194(5):249–52
  11. Hayman N. Chlamydia PCR screening in an Indigenous health general practice clinic in Brisbane 2002–3. Brisbane: 2004
  12. 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
  13. Queensland Health. Indigenous sexual health service report for Brisbane Southside. Brisbane: Communicable Diseases Unit, 2004
  14. Heal C, Jones B, Veitch C, Lamb S, Hodgens S. Screening for chlamydia in general practice. Aust Fam Physician 2002;31(8):779–82
  15. Scholes D, Stergachis A, Heidrich FE, Andrilla H. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;334(21):1362–6
  16. 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):65–8
  17. STIs in Gay Men Action Group (STIGMA). Sexually transmitted infection testing guidelines for men who have sex with men 2010. Sydney: STIGMA, 2010 [accessed 2011 June 6]. Available at www.stigma.net.au/resources/ STIGMA_MSM_Testing_Guidelines _2010.pdf
  18. Whiley DM, Garland SM, Harnett G, Lum G, Smith DW, Tabrizi SN, et al. Exploring ‘best practice’ for nucleic acid detection of Neisseria gonorrhoeae. Sex Health 2008;5(1):17–23
  19. Australasian Society for HIV Medicine. HIV, viral hepatitis and STIs: a guide for primary care. Sydney: ASHM, 2008
  20. Guy R, Wand H, Franklin N, Fairley CK, Chen MY, O’Connor CC, et al. Re-testing for chlamydia at sexual health services in Australia, 2004–08. Sex Health 2011;8(2):242–7
  21. 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
  22. 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
  23. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. MMWR 2006;55:38–40
  24. 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
  25. Ministry of Health. Draft chlamydia management guidelines. Wellington: Ministry of Health, 2008
  26. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: Annual Surveillance Report 2011. Sydney, NSW: The Kirby Institute, the University of New South Wales, 2011
  27. Atkins D. First new screening recommendations from the third US Preventive Services Task Force. BMJ 2003;327:21–4
  28. 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
  29. Burnet Insitute. Partner notification of sexually transmitted infections in New South Wales: an informed literature review. Melbourne: Centre for Population Health, 2010 [accessed 2011 June]. Available at www.stipu.nsw.gov.au/content/ Document/Contact_Tracing_Literature.pdf
  30. Honey E, Augood C, Templeton A, Russell I, Paavonen J, Mardh PA, 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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