Sammi:
Good evening everybody and thank you for joining us this evening for our STI and HIV Care Forum: Ask anything. Tonight’s forum will allow you to ask questions of our sexual health specialists that we have on our speaking panel to help you gain some confidence and knowledge in STI and HIV consultations.
Before we go any further, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present.
I wold like to formally introduce our presenters for this evening now. We are joined by Dr Catriona Ooi. Treeny is the Director at the North Shore Sexual Health Service in the Northern Sydney Local Health District. Dr Tim Senior is a GP at Tharawal Aboriginal Corporation in South Western Sydney. He is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health. Dr Lawrence Vaux is a GP at Alice Street General Practice in Newtown, and recently has worked in various roles in the New South Wales COVID response. And finally, Miriam Delailomaloma, Health Promotion Officer from the Northern Sydney Sexual Health Service. Her key priority groups are young people and men who have sex with men. So, thank you to our four presenters for joining us this evening, and I am going to hand us over now to Dr Tim Senior, who is going to kick us off with our learning outcomes for this evening. Thank you, and welcome, Tim.
Tim:
Thank you very much. I hope you can all hear me okay. Good evening everyone. These are our learning outcomes, which are education-speak for what we hope to get out of the next hour or so. So that by the end of this CPD activity, we should all be able to describe HIV and STI epidemiology in New South Wales. We should be able to increase our confidence and knowledge in comprehensive HIV and STI prevention, testing, treatment and contact tracing as part of our routine care. Identify barriers and solutions for HIV and STI general practice consultations, and identify support resources and referral pathways for HIV and STI consultations. And I think we are starting off with a poll.
Sammi:
We certainly are, Tim, and I am just launching that poll now, so that should be showing up on everybody’s screens there, and you can select your options. This polling is completely anonymous.
Tim:
So, on this one, we are just inviting you to rate your knowledge and confidence of HIV and STI care, as whether you are a specialist GP through to very low. And, it is anonymous, so please be honest. And I would, I know, certainly I would not be rating myself in one of the high ones even though I am one of the facilitators tonight.
Sammi:
We had 64% of people rated themselves as average.
Tim:
Which I guess is statistically appropriate. Most are average, and some of us feel we are above average, and some below average. Interesting as GPs, none of us consider ourselves very low. I suspect that is because we are all doing a bit of it and we have got some real experts online which we are very grateful to have you here. Thank you for rating yourselves on your knowledge and confidence, that is great to see.
So, we are just going to start off with thinking about the consultations that we have, and feel free as we go along, you can see the red arrow there pointing to the Q and A box, so that people can actually put questions in as we are going. We are hoping to answer as many questions as we possibly can tonight. And we will just start off talking about, in order to actually talk to people about HIV and STIs, we actually need to be able to see them and have a consultation with them. So, that is a great place to start. So, Treeny, what concerns do patients have when accessing sexual health care at GPs from what you see in people choosing to go to Sexual Health and not to a GP?
Treeny:
Yes, we often have these conversations with patients at times when we are triaging them back to their GP or when we are just letting them know what their GP can do, which is pretty much everything. Things that people have mentioned to the clinic and me as well, are, it is difficult to open up to GPs. They are worried about, you know, their families or you have seen them before. They are not so much afraid of being judged, but that embarrassment and having to raise that topic with their GP. So you know, that sort of stigma. People come to us because they have had bad experiences with their GP in the past, so we have all heard stories about somebody who goes in with primary herpes where nobody even looked at their genitals or they were just immediately sent off somewhere else for example, or they had very limited time, so they did not feel they had the permission to discuss something like that. So, that embarrassment, the confidentiality and stigma associated more than anything else.
Tim:
Thank you very much. And Lawrence, how can GPs come over those barriers and make providing sexual healthcare easier and part of our routine clinical practice?
Lawrence:
Yes, so I guess you know, in making it routine, you kind of destigmatise it a bit. So just making it part of that annual health check, contraceptive script, you know, even sometimes when you are just checking a patient’s details, and just going, are you in a new relationship? Are you still in the same relationship? That can sometimes be a bit of a springboard. And if you want to involve a nurse, you know, some places like where we work, the nurse will do some cervical screening and as a part of that she can involve some kind of sexual health counselling or questions that we might get involved if they become a bit more complex. And I guess everyone does GP management plans, and they get reviewed. And I think most practices, that is often run by the nurse, and we have tried to tie in a little bit of sexual health education into that. And again, that is just a springboard to, is this something that you want to talk about? If you need more detail, we are ready to kind of get involved in that step.
Tim:
That is really good. Are there some things that practices can do to let the patients know that sexual health is something that can be discussed with GPs? Are there things that we can do in terms of our marketing to make that a legitimate topic of discussion or make patients feel comfortable bringing it up?
Lawrence:
Yes. I think, look, where I work, it is part of my little bio. This is something that I do. And definitely people come in expecting that. But I think you know, the easiest thing is just having posters around. You know, you would be surprised how many times patients walk into my room and say that they have seen something, and it just helps them walk into the space and feel comfortable talking about it. Because they already know that this is a safe space or it is something that we practice. So, I think just those small little reminders to make people aware that you know, we are comfortable talking about it as well.
Tim:
Excellent. And, Miriam, I think you often come across people who are a lot younger than myself and hear about their attitudes and the challenges they face in accessing sexual healthcare. What challenges do you see, and how can GPs alleviate those?
Miriam:
So I actually asked a group of young people these questions. So, this is what they have said. So these are the youth health consultants that I have asked. They are young people that are part of North Sydney LHD who are paid to be the voice of young people, and we collaborate with them for health promotion campaigns and to make things youth-friendly, youth-friendly health services. So, this is what they said. So they said that really they have lack of knowledge that they can actually go to a GP for sexual health concerns. They did not know if they could use their parents Medicare card, like if they had to have their own Medicare card, and what sort of ID do they need. They wanted to know what the age limit was, do they have to pay, what do the GPs actually offer them that is more than a Google search, like what is the benefit for them? Confidentiality, just like Treeny, Lawrence mentioned, that they were worried that the GP might tell their parents. And also the parents would transport usually to the GP, so that was also a barrier. They also said there is fear of similar, well actually, they said fear of judgement from the GP and intimidation. They were unsure what the GP might believe, so they thought they could be told to stop sexual activity by the GP. They were unsure what age was okay to actually ask sexual health questions, and they thought they might be judged for asking some questions too young. And also cultural backgrounds, they said that in some cultures, talking about sexual health or anything related to sex is really stigmatised and unaccepted. And then, self stigma. Sexual health information they received at school they said was really inadequate. So they did not know where they could actually ask sexual health questions. And then fear if they did tell the school, that the school would tell their parents. And they could not talk to their parents because some of their parents were not open to this topic and they thought it would be really awkward. And they also said there is a stereotype that GPs are really formal or uptight. That is what this group said.
Tim:
That is really helpful. And a lot of those might be concerns that we might take for granted about just sort of routine access to care, and I think knowing that is really useful for us in being able to address those concerns. Are young people happy to use telehealth, Miriam? I want to ask you if telehealth can be helpful in doing sexual health in general practice as well?
Miriam:
I did not actually ask the young people this question, so I am just guessing, and I have been working in this role with young people for a few months, so I think yes. But then it comes back to the same barriers, like they did not know what the GP could offer. So, maybe if we overcome that barrier, then the telehealth would be useful. But first they need to know that they can actually talk to the GP about this.
Tim:
Yes. Have you been using telehealth, guys?
Lawrence:
Yes. I use it a lot. It is probably what I have been doing predominantly for almost two years. I think Miriam nailed it. I think she said exactly what needs to be said on this subject, which is, if you have good rapport with a patient, you know them well, telehealth is really convenient and works really well. And if you know how to do everything digitally, you know, you can send them a text and that allows them to do all the screening they need to do. But as an initial consult, it really does not work well. It is really hard to build rapport, and you know, it can be really hard for people to open up to you. You know, that said, for some people, you know, there is a little bit of a barrier in you know, talking face to face with someone. So there is the odd person where obviously removing themselves, it is easier to ask the more difficult questions. But I think for most people, if you do not have a relationship with them, it does make it a little bit more difficult.
Tim:
Sorry, I was just being checked up on by one of nurses here at work. Which actually brings us through, I would just like to think that there is a whole practice team, and the whole practice system and use of our software, and making sure we are identifying all the patients who might need sexual health checks, using our software and our team system systematically and quality improvement I imagine could be quite useful in doing it as well. And it is also worth mentioning that there are free condoms available for young people via the Play Safe program. I think we have got the resources for that coming up, too. And again, it is just really important that unless there is the rapport, the conversations actually do not happen in a way that can be.
Treeny:
Can I just ask people online, if you do have any hints or tips that you think your colleagues would benefit from, then please put them in and we can filter them out to everybody else. Because certainly, we have all got different cohorts and we all treat different people, so there may be different ways to make it easier for our patients. Coming from a sexual health background and working in a sexual health centre, it is very easy for me, because there is implicit understanding that you know, you are going to be asked about sex, and that is why they are there. So, I would love to hear what other people did.
Tim:
Great. And there will be a lot of expertise in the audience here. And I think the advantage we have as GPs as Miriam was saying, is that people can be in our waiting rooms and no one can guess what they are there for, but if you are in a waiting room for a sexual health clinic, it is pretty clear what sort of problem they are going to be there for. You can tell all your friends, I have just got a sore elbow. And ensure confidentiality.
Miriam:
Tim, I did just want to mention, I asked the youth health consultants what they suggested could remove these barriers. So, if you want me to share that now?
Tim:
That would be great actually, yes, thank you very much.
Miriam:
No worries. So it was really useful. So they said, really similar to what Lawrence actually talked about with the bio, the GP bio. So, firstly they said, explain what services you actually offer to young people, so maybe a flier or sign in a waiting room saying you can talk to us about sexual health. They mention maybe a sign saying this is a safe place to talk about sex, safe sex or young people and LGBTIQ+. So they mention, like a sign like this. Can you see that sign? Okay, cool, so they said that would be really helpful. It might make people feel like they are able and open to share. They said that maybe you could have a sign saying if you are under 18 and have sexual health questions, you can ask us. Or, we are not going to judge you. So, there is already posters on the STIPU website under the resources. You can actually order these for free. So these already exist, this kind of thing. Can you see that?
Treeny:
We can give everyone the resources and how to access them at the end of the program.
Miriam:
Yes. So these already exist. There are heaps of posters that say, everything you need to know for a healthy and confident sex life. And they link to Play Safe. So, Play Safe is a New South Wales Health sexual health website that is specifically for young people. So it has everything sexual health related specifically for young people by New South Wales Health. So, you can link people to that by those posters and just let them know you are open to talking about that. That is what the young people said. They said, have a sign saying what you provide, like what services are offered here. And then they said the website is so important for them as young people. So have on your website how to book an appointment. What is offered, is it free? Have a photo of the GP’s face like Lawrence said. And the bio was really important to them, and they even mentioned a video, where the GP says, hi, I am blah blah, and then maybe a few lines about what they offer. So that seemed really, really valuable to them. They said that maybe having basic sexual health information on your website that is trusted, and then that website maybe could say, when do you actually need to talk to a GP when it is more important. So you could actually link to that Play Safe website on your website, perhaps. Make young people feel welcome to talk to you about sexual health. So sit with them, reassure them, make the environment more friendly, and clarify that medical care is not just for emergencies. And remind young people that they have the right to confidentiality. Maybe a sign or a statement that you could say to them, it is a private talk. And they said that the GP could ask the parent to leave the room when you talk to their child about sexual health, so the child could be open. Yes.
Tim:
That is really helpful. I think it is difficult for us to estimate quite how unusual it might be for many young people to feel that it is “their” doctor. I remember a comment talking to young people about seeing “their” GP for I think, for COVID related things. And one young journalist commented that asking them to see “their” GP was a bit like asking them to see their blacksmith. It was really quite out of their scope, and building up that rapport I think would go a long way to making people feel that yes, that actually is my GP. Thanks, Miriam that was really helpful. And that is the STIPU ordering resources link that has gone into the chat box for you.
Sammi:
I might launch our second poll off now, Tim.
Tim:
Thank you.
Sammi:
And while people are responding to that, in response to what Treeny said, we have had a comment come through that really mirrors what Lawrence said in that they are finding it very difficult to do telehealth for STIs if the patient is not well known to them, and there is not that mutual trust. So, a couple of people have liked that as well. So it looks like that is something that a few people, a few GPs are struggling with at the moment with telehealth in that respect.
Tim:
So, next poll. During the COVID-19 pandemic, the number of notified STIs in New South Wales has: gone up, stayed the same or gone down?
Sammi:
So we had 61% of people say decreased.
Tim:
Treeny, who gets the chocolate?
Treeny:
The 61%. I do not know if we have 40 chocolates, but it has decreased. And shall I, I might go through the epidemiology now, because we have got a couple of cases as well. So in the interest of time, I think first of all just going through HIV, you can see that there has only been 187 notifications in 2021, and this can be attributed to the fact that people’s behaviour has changed but also the advent and introduction of PrEP has made a huge difference. This was almost a third less than the average up until 2020 from 2016 to 2020. So it is quite a significant decrease.
You can see here that most people are diagnosed in general practice, and they are not the S100 GPs. And for those of you who do not know, S100 means that you prescribe anti-retroviral medication. So, it is mostly GPs who do not really see a lot of HIV, and do not manage HIV independently. So it is great that everyone is testing.
Okay, so one thing that we have noticed in the most recent notification data is that people who are diagnosed early in their infection, those with a proportion of diagnoses of early infection has decreased, but the proportion of late diagnoses in corollary to that, has increased. So most people are diagnosed, the greater number of people who are diagnosed, the greater proportion of people who are diagnosed, had their infection for a long time. So, this also really speaks to the success of PrEP, and that is HIV pre-exposure prophylaxis.
One thing that people have asked is with PrEP is, if you had unprotected sex in the last 72 hours, can you start PrEP? Essentially, PrEP is very, the medication for PrEP is the same as PEP medication, which is post-exposure prophylaxis. So, unless that patient requires three drug PEP, then you can start PrEP, which effectively for the first month acts as post-exposure. However, if you are unsure, then please call up someone to ask their advice, and you can call your local sexual health clinic or ID person, if there is no one available, then you can call the sexual health info line and we will have those contacts for you at the end of the talk.
Syphilis has been a real eye opener, actually. So, the rates of syphilis have been increasing over the last few years, and we are currently looking at epidemic proportions in men who have sex with men in particular. Most interestingly, and probably most instructive for us all is that syphilis in heterosexual populations has increased, so we are seeing more syphilis in heterosexual men and women. Particularly concerning, is women of childbearing ages, and as a result of that, we have seen an increase in congenital syphilis. And that is interstate as well as New South Wales. But it is something to be aware of. Patients need to be, just because you are seemingly low risk, does not mean you could not have an STI such as syphilis. If you are concerned about syphilis, there are particular signs and symptoms that you can look out for, although the majority of people will be asymptomatic when they are diagnosed. But in particular, the primary chancre, which is a painless ulcer, in secondary syphilis you can get a rash, which is typically on the palms and soles of the feet, although can look very different to a typical syphilis rash. Syphilis is also known as the great pretender, so it can manifest in different ways. Not everyone will have the rash. Some people will get mucous membrane patches, some will get patchy alopecia, but generally the most common sign and symptom in secondary syphilis is a rash, and in primary syphilis, is the chancre.
Moving onto chlamydia. Chlamydia is the most commonly notified STI in Australia, and has been for like 15 years. The rates are not decreasing. The seeming dip in this slide here is a result of changes to testing patterns because of COVID-19. But we are still seeing significant amounts of chlamydia in young men and women in particular, as well as older heterosexuals and men who have sex with men. Now, if you are concerned about what to treat these STIs with, then I suggest, I can talk to you about the individual treatments for chlamydia, gonorrhoea, but online is freely available and updated regularly, the Australian STI Guidelines, which will tell you how to screen, how to test, what symptoms to look for, and what is the first line and second line treatments.
Gonorrhoea again, we have seen a change in testing behaviours with COVID, so a dip in those last few years, but we still are seeing enormous amounts of gonorrhoea, particularly in homosexually active men, although we are currently seeing significant amounts in indigenous populations and heterosexuals also. The problem with gonorrhoea, is there are rising rates of resistance. Our first line treatment is intramuscular ceftriaxone and there have been reports of resistance to ceftriaxone, in which case patients are being treated with things like gentamycin, spectinomycin, and a whole lot of different things. So it is really important if you have somebody who has tested positive for gonorrhoea to check your guidelines. Make sure you are giving them proper first line treatment if possible, and to also get swabbing done for antibiotic sensitivity testing. Really important to make sure that your patient can be adequately treated, and also for surveillance.
Tim:
Marvellous. Thank you, Treeny. We are going to launch another poll I think. But there is a question that has come through on syphilis, which I think is one of the ones that is going to come up regularly, certainly I was finding it difficult to get my mind around it. Treeny, you were suggesting you wanted to answer this question live, about shedding some light on syphilis serology, and how you can differentiate between previous syphilis infection and new infection.
Treeny:
Sure. Do we have a half hour that I can go through?
Tim:
Each lab or company perform their own set of serology tests it feels like.
Treeny:
Yes. Look, you need to do a combination of treponema specific and treponema non-specific tests. So, that is the RPR or VDRL, plus the EIA, TPPA, FTA-ABS or TPHA. So you need to do a combination of all of those. Most labs, if they do a positive screening test, will go on to run the whole panel of tests. If somebody, you have to combine their syphilis serology and the pattern of the testing with their previous history and last negative test, or last RPR. It can be quite complicated and I do not really know that we have time to go through how to interpret all different combinations of those, but I suggest that if you are concerned, or if you have a specific question, I am happy for somebody to email me, or you can contact your local sexual health clinic or the STI info line.
Tim:
We have got the poll running. In my general practice, the most difficult part of HIV and STI testing is: and choose one of those answers. And the best answer that you think of those. You do not get to choose more than one or a different one, I am afraid.
Sammi:
And here are your results.
Tim:
Lovely. So, that is very interesting. We have got a lot of people saying positive results and contact tracing. And second to that, starting a conversation about HIV testing, hold that in your thoughts, that is what I am moving onto next. Closely followed by knowing who should be tested, closely followed by taking a sexual history. And I think, and then coming in last, having enough time to test. And I think taking a sexual history, it is important that not only are our patients uncomfortable doing that, but we have our own levels of discomfort doing that, and sort of practicing doing it and getting used to doing it, particularly as GPs where we are doing all sorts of other histories as well. They are getting comfortable being able to ask in a non-judgemental way. But recognising that it can be uncomfortable doing that and overcoming that because it is important, can be really important.
Starting a conversation is actually our next slide, I do believe. Because it is one of the common things. It is actually about the tips for HIV and STI testing, and we will direct you towards the STI/HIV testing tool, which is available on the STIPU website. And the first step in that is starting a conversation about sexual health testing. And so, Lawrence, Miriam, Treeny, what advice do you have? How do you start conversations about STI testing with people? I guess it is slightly different for GPs than it is for sexual health clinic specialists. How do you start, Lawrence?
Lawrence:
Look, I guess a lot of people request it, but how do I start? I often start with actually, this might kind of go back to what we were talking about before with stigma in kind of acknowledging the fact that there are stigma behind STIs. Because I think ignoring that is a little bit silly. But within that, you can kind of jump to the statistics, with like what Treeny talked about, and I think talking about how common they are, and just because we do not talk about them, does not mean they do not exist. And I think that is where I try to start off, to say that this is something that exists, is really important, and just because it is often not part of our kind of general discussion, that it is still something that you know, that exists within the community and is really important to do. So that is kind of where I start. What do you think about that, Tim?
Tim:
Yes. I think one of the main differences we have is that initiating conversations when people are attending our clinics, they often have got symptoms. But very often they are coming to us for other reasons, they might be worried, and we have to start that conversation with people who do not have symptoms. And some who may be worried about it and some who might not have thought about it at all. So being able to sort of judge where people are on that scale, and deal with that appropriately, I think is going to be quite important, too.
Treeny:
I think in some ways, depersonalising it is very good. So I am adding this to everyone’s check-up. Or you know, we have been given guidelines, everyone under the age of 30 should be checked for chlamydia or gonorrhoea. So I am asking everybody. So, that person in front of you realises that it is not, they are not being judged, it is just something that everyone is doing. I see a number of patients who are HIV positive, who are otherwise at very low risk. So they are heterosexual, they are HIV positive, they might have been infected via you know, something that was not sexually related for example, and I will say to them, has anything changed for you in your private life? Do you need a sexual health screen? And that way, they can tell me what they want to do. I have opened that door and given them permission to discuss anything that they need to, but they do not feel like I am saying, it is you, you are the one that has to have it, I am worried about you because of X Y Z. And I do not know whether that would chime with some of the patients you see in general practice, but it seems to work for a very, very low risk group that I see sexual health wise.
Tim:
I would imagine that is really useful for people without symptoms. We are doing this testing on everyone now, so would you like to be part of that? And I think it is worth being familiar with particular groups where it is going to be particularly important. I mean, I am imaging how important congenital syphilis is, so making sure we are having those discussions with pregnant women, and I think they have brought in an extra antenatal screen for some women at 28 weeks. And congenital syphilis is just so damaging, that it is absolutely worth picking up and treating.
Treeny:
And completely avoidable.
Tim:
Absolutely. We often talk about language being normalising and non-judgemental. What exactly does that mean?
Treeny:
I think for me, it means not using stigmatising terminology or terminology that patients may view as stigmatising. So I do not say, are you gay or are you straight? I will say, have you ever had sex with a man, have you ever had sex with a woman? Things like, I do not ask, were you safe or unsafe? I will say, did you use a condom, did you not use a condom? So, removing that sort of, those values, those terms that are laden with value from what I ask, and just asking things like, I ask, did you have oral sex, anal sex or vaginal sex? You know, just make it very clear, more functional than it is about their sexuality or about their personality or their risks for example.
Tim:
We have got some good comments come through as well about bringing it up as part of routine preventative health topics. And commenting that it can be easier with a discussion about contraception and that often comes up more for women than for men, but we can also have discussion about contraception with men as well.
And similarly, a useful point here, positive results are hard. We do lots of screening and do not necessarily make appointments to discuss the results every time, and you get booked out. So it becomes a practice time management issue, and I think that is important, that it is not just about us in a room with a patient. The system that the practice operates in terms of following up results in terms of having appointment times and methods of contacting patients is going to be important in that, too.
Treeny:
Yes, we do not make appointments to give results to our patients. We work on a no news is good news except for, I will make appointments for follow up if there is some sort of concern. But generally we do not. Patients know it is no news is good news. But I will often flag with them what will happen if they are positive. So, if you get a positive chlamydia result, we will contact you. Someone will contact you, blah, blah, blah for example. So they do not get a call and start freaking out.
Tim:
Miriam, are there differences in sexual healthcare for young people compared with older adults?
Miriam:
A lot of the things that the young people said were really similar or exactly what Treeny and Lawrence already have said, but they did mention, do not have the parent there unless the child wants the parent to stay. So, they said that you cannot get an honest answer or open answer with the parent there, and they said the same as what Treeny said, when talking to young people, do not use a lot of euphemisms, they want you to use the words, like for example, use the word sex, use the word gonorrhoea. They said, young people know a lot, treat them like normal people. So exactly what Treeny was saying.
They did have a few do’s. Would you like me to go through that?
Tim:
Yes, please. That would be great.
Miriam:
So, they said let us know where we can get tests and what tests are available and what is the process? Do we come back next week, how long does it take, do we get it in the mail, what is the cost? So, same as before, a lot of unknowns about what is the process. They said, yes, please normalise the topic of sexual health testing and sexual health. Validate it is okay for young people to talk about this with their GP as a way to just look after our health. Frame it in a positive way, the whole topic. As we said, commonly offer STI testing if a young person is sexually active. They mentioned a pocket card with information that a GP could give to young people, maybe when they are in their teens, including prompts on how to bring up STI testing or how important testing is. And we already have this on the Play Safe website. There is this card which just says everything you need to know for a confident healthy sex life, and it just links to that sexual health website. So perhaps you could just have this in your clinic to give to young people. And then they said, please include information on how to bring up testing with a partner.
Tim:
That is really good. I imagine, some of that simple, practical stuff around sample collection or explaining that some things are a urine test, a blood test, a swab, can be really useful. And just the privacy around that. Like, carrying a urine pot, sort of like providing a bag to put that in, just like simple stuff I think can make a difference and it just looks thought out, people’s experience of it. Anything that you would add, Lawrence?
Lawrence:
No, no, I think those are all good points. I think destigmatising it, depersonalising it, making it very kind of methodical, and I think yes, giving young people their own space. I think those are all really good points. I think you know, back to what the person wrote in their question, and we talked about it a bit earlier, is making it a part of your conversations with contraception, I think that is a really good thing. It is a little bit more complex with young men, obviously because they do not come to GPs for contraceptive needs most of the time. But yes, just making it part of the routine care. I think you covered it quite well.
Tim:
Excellent. I would imagine Treeny, you do this a lot. Lawrence I think you do this a lot. It gets easier with practice, doesn’t it?
Treeny:
Yes, it does.
Tim:
So just having a go at talking about sex with all your friends and colleagues. You cannot go wrong. But just being able to practice it, actually you get more comfortable and you get better at doing it and the terminology comes more naturally.
Now, unless anyone else has any other burning points. Oh, Treeny, did you want to say something about the HIV Support Program as well?
Treeny:
Oh, yes, sure. So, I think a lot of people, a lot people are concerned about testing for HIV in the event that there is a positive result and not knowing what to do. And this can be particularly if you have not made an appointment to see that patient. But there is this program throughout New South Wales called the HIV Support Program where you opt in or opt out, and what happens is, for every new diagnosis of HIV, you will have the option to have somebody call you, the HIV support program coordinator in your area. If you are in the Northern Sydney Local Health District, it is me. I will ring you if you are happy to accept my call, and say, okay, I am a specialist, I work at Clinic 16, what do you need? What can I do to help you? Do you need help giving the result? Do you need help contact tracing? Do you need help providing support for that patient? Places to refer them? Anything you need, I will help you with. We have given patients the result, we have provided them telephone support, the patient telephone support. In the interim we have received the referrals for patients and we will keep you up to date as to what is going on. So it is a really, really great service. I know GPs are busy, so you opt the time that is best for me to call you and I will do my best to call you at that time and on those contact details.
Tim:
Lovely. We have got a question here. For a positive result, what is the best way to urgently call the patient? It is a good question. I guess my take on that would be three fold. One is, our practices already have ways of urgent recalling patients for any result, and so the practice system that works for that will also work for urgent STI results. And the second thing to suggest would be just being aware of the sensitivities around that, so maybe be careful about sending text messages to people saying there is a result we need to discuss rather than saying what particular test. But I think there is an opportunity as well when we are doing the testing to say, how would you like us to contact you if this result is positive? So you agree that beforehand with the patient, discussing what the implications of a positive test and what needs to be done, and how they can be contacted in a way that they will feel comfortable and not shocked by. Would you do anything different, Lawrence?
Lawrence:
No, no, no, I think that is it. I have like a series of kind of texts that I send for different levels of severity, but in something that I would have urgent, I would call most of the time if I need someone in within 24 hours and I just make sure that in my days I have at least six appointments each day that will only be made available that morning, so will always space to fit someone in if there is an urgent abnormal result. And going back to what Treeny said before around the HIV diagnosis support, it is really useful, I actually had to use it on an AIDS diagnosis that I made not that long ago, which was quite surprising and all the resources and the team that I worked with at RPA were amazing and really helpful.
Tim:
Lovely. I am just looking at the questions coming through, and the cases that we are discussing. Some of those questions we cover in the presentation. Shall we move onto the next case and see what we get to in terms of the questions?
Treeny:
I think we should move on. We have got less than 15 minutes left, and we have got two cases. So we might not get through them both, Tim.
Tim:
Cool. So, this is case study one. This is Hanna, who is a 20-year-old woman, and she presents stressed as her partner disclosed this morning that he has sex with men, and one of his male partners was diagnosed with syphilis. She is late for her period. She thinks it may be due to stress though. She is very worried about syphilis, HIV and other STIs, as they do remain sexually active together. Her partner is going to see a doctor today, but there are not any test results available. So, what are your thoughts on this case?
Treeny:
Are you asking me? Or are you asking everyone?
Tim:
I am asking anyone who wants to answer, but we will start with you, Treeny.
Treeny:
Well, first of all, you will need to have a bit of a sexual history and make sure that Hanna is by herself. Often patients will come in with partners and family members, and I always ask to see them by themselves first of all, because often there are things, they might say so-and-so knows everything about me, but believe me, they will not. So I think it is really important to get them by themselves, like the young person and parent. You need to do a sexual history. The partner who is having sex with men may not be the only partner involved with this woman, so I think it is really important that we get a sexual history as to her risk. Things that we need to do are, make sure that she is not pregnant, a full sexual health screen. Give her some information about syphilis, HIV and STIs, and protect her now. So, I would ask her if she is concerned, particularly if she is pregnant, to abstain from sex until we have some results, until her partner gets results. Currently she is a contact of a contact, so her risk, we do not know what her risk is. But I would be concerned about her being pregnant and with syphilis. They are my first thoughts.
Tim:
Yes. Lawrence, what would be your approach?
Lawrence:
Yes, look I think that is 100% the right thing to do. I think doing a pregnancy test is top of my list, because obviously that makes treating potential syphilis exposure much more time critical. And I think that is something that we can definitely do with urine pregnancy tests in our clinic. I think most GP clinics would probably have them on hand. And then I guess, you know, apart from doing that is also you know, congenital syphilis is a really complex thing, but congenital syphilis only happens once syphilis is contracted and transferred through the placenta. So, having a bit of an understanding about how that potentially happens and then, you know, if she is very early in the pregnancy, I mean without getting too technical around syphilis in pregnancy, you know, being reassuring that this is something that we can treat if it is a potential, and it may never actually cross the placenta. So, yes, you know, I think Treeny’s approach is perfect and I would just be doing a pregnancy test in the clinic, and reassuring the patient that you know, if there is an issue, this is something that we can definitely manage.
Tim:
Yes. How soon would we expect her to have any symptoms at this stage, or to test positive to syphilis at this stage?
Treeny:
I do not think we know that at the moment. You get symptoms as early as nine days after infection. We do not actually even know if her partner has syphilis. We only know that the partner’s partner has syphilis. So we are a few steps away from actually being that concerned. So she is not a contact. She is a contact of a contact. So, several degrees of separation there. So, I think we can tell her what to look out for, but as I was mentioning before, most people diagnosed with syphilis have no signs or symptoms.
Tim:
Absolutely. And so, alongside the possible pregnancy and potentially managing syphilis, we are also managing her anxiety about syphilis and HIV and STIs as well and it is an important thing for us to manage. It is not misplaced anxiety, but we need to be managing that, too. Any other thoughts? Are there particular circumstances where this might put her at higher risk? Any particular population groups that might make us worry more?
Treeny:
She might be a sex worker, for example, in which case she would be a priority population. Other priority populations include Aboriginal and Torres Strait Islanders, they have higher, the case numbers are higher per population in that group. I think one thing that I always like to know, is have they had STI testing before. Because that way we can at least have a baseline negative test I am assuming, but we cannot assume. If they are also an injecting drug user, or if they have had multiple partners. As I mentioned, the male partner who is a contact of syphilis may not be the only sexual partner.
Tim:
Yes. Someone is asking if we would consider PrEP for this woman, for Hanna?
Treeny:
She would not be on my high risk group. I mean, that is not something I would be concerned about unless there was something else in her case history or sexual history which alerted me to that. Having a partner who is a contact of a contact, does not make you at risk of HIV. If she was having multiple partners, if she was having a lot of anonymous partners, there may be more of an argument. Or if she was having partners from high prevalence countries for HIV, then she would be at high risk. But, there is nothing there that I would be concerned about at the moment.
Tim:
Lovely. We might move on to the next case actually, because I am just keeping an eye on the time there. This is case study two. This is Marty who is a 23-year-old man and he presented two weeks ago reporting a mild dysuria and urethral irritation for three weeks. The sexual history is sex with women only, he sometimes uses condoms, he has had seven partners in the last year. He drinks at the weekend and does not inject any drugs. He has had chlamydia, gonorrhoea, syphilis and HIV testing, and that is all negative. He was prescribed one gram of azithromycin which helped the symptoms for three days, but then they slowly returned. So Treeny, what are we thinking here?
Treeny:
Well, the gonorrhoea and chlamydia tests are negative. They are the common causes of urethritis that we see. If they were recent tests, so from when he presented two weeks ago, then I would be concerned that there was another infection there. So, other things which can cause urethritis or nongonococcal urethritis include adenovirus, HSV and of course, everyone’s favourite, mycoplasma genitalium. The azithromycin may make a difference, it can decrease some of the inflammation but the symptoms will remain. And so I would be concerned that he had a viral cause. In which case, the azithromycin is less likely to make any difference. But I would be concerned about mycoplasma genitalium with macrolide resistant infection.
Tim:
Fantastic. Lawrence, how would you approach this in general practice?
Lawrence:
Yes, so exactly what Treeny said, you know, you have got to think of other causes or some causes of NGU, and I guess you know, just testing for mycoplasma would be my next step before potentially you know, discussing further treatments. And then obviously inviting them to abstain from sexual intercourse. And then you have got to figure out whether it is potentially macrolide resistant or not. I guess the complexity with it potentially being macrolide resistant and it is not something that I would treat a lot in GP, because of the cost of the antibiotics to actually get moxifloxacin over the counter, I think it is like 80 or 90 dollars, I think. And normally that would be provided by a sexual health clinic for free, if that is correct Treeny?
Treeny:
I think it depends which clinics you go to, but we provide it for free. If somebody, I think one thing to point out here is, if somebody comes in with mild dysuria and urethral irritation, so they have got a urethritis, the first line treatment is not azithromycin. The first line treatment is doxycycline. The reason for that, is because if you give a gram of azithromycin, which is the treatment for chlamydia, you are undertreating mycoplasma and what you do, is you select for a resistant organism. So, if you give a gram, then you are almost certainly going to get a resistant mycoplasma. You are better off to give doxycycline and then if you diagnose mycoplasma, you may then be able to treat them with higher dose azithromycin. If not, you do not waste your time with azithromycin, you just go straight to moxifloxacin. One thing, and this is all on the STI Guidelines on how to treat that, that you treat them with dual antibiotics. You have doxycycline plus usually higher dose azithromycin or moxifloxacin or even pristinamycin. You need to give a week of doxycycline first, because you decrease that bacterial load. Very few mycoplasma subtypes are treated with doxycycline, but you will decrease the amount of bacteria there. So whatever antibiotic you use next will have a better likely success.
The other thing to keep in mind, and this is really important, is that if somebody is asymptomatic, so you are just screening, mycoplasma testing is not recommended. So you only test for mycoplasma if they are symptomatic.
Tim:
Cool. That is important, because that was one of the questions coming through. Thank you, Treeny.
Lawrence:
Treeny, would you have treated this person with doxycycline prior to testing for mycoplasma?
Treeny:
Well, we automatically test everyone for mycoplasma who has got urethral discharge. So, I would have given them a week of doxy, because they have got urethritis. Usually what happens then is the mycoplasma test will come back as positive, and that way we will know whether it is macrolide resistant or not, because it is part of our testing and most labs will do that. And so that way, I will know whether or not to give them higher dose azithromycin or moxifloxacin. But if say I gave them, I waited and they had doxycycline and then it comes back a little bit later and there was a gap, I would treat them again with doxycycline followed immediately by whatever medication it was for the moxifloxacin. So, the treatment for mycoplasma is automatically doxy plus something else. Does that answer it?
Lawrence:
Yes.
Tim:
And just to be clear, the indications for mycoplasma genitalium testing are acute, persistent and recurrent nongonococcal urethritis, cervicitis, pelvic inflammatory disease, post-coital bleeding and people who are ongoing sexual contacts of people with mycoplasma genitalium infection.
Treeny:
Yes. So, people are either, it is either a test of cure for someone who has already had it, or they are symptomatic. They are the only times you would, or they are a contact. They are the only times you would test for mycoplasma.
Tim:
Lovely.
Treeny:
Screening, no. No testing.
Tim:
Excellent, that is great. We have actually hit half past eight and the next slide is around contact tracing, and I do think that is a bit important. We have had questions come through on contact tracing. The slide shows the three different websites that are really useful. So there is Better to Know which is useful for Aboriginal and Torres Strait Islander people. The Drama Downunder.info, which is really useful for men who have sex with men. And LetThemKnow.org.au, which is a general website for everyone. And they help with contact tracing where people can actually anonymously send an SMS. And then sometimes Treeny, there is more complicated contact tracing required, and I think the sexual health clinics have methods of getting to people through Facebook messenger and things like that, is that right?
Treeny:
We use these websites. The other thing we can do, and I know a lot of GPs are busy or do not have the capacity to do the contact tracing, is there is a state-wide contact tracing service, and that is available via SHIL, the Sexual Health Info Line, and I think, yes, the Sexual Health Info Link down the bottom there. The second one after the RACGP logo. So you can contact them and they will do the contact tracing for you. The other place you can go, is you can go to your local sexual health clinic, and we will do it for you. Easy peasy.
Tim:
Excellent.
Treeny:
But it is the duty of care of the doctor, the diagnosing clinician to initiate contact tracing. It does not mean you have to do it, just means you have to initiate the contact tracing and let your patient know that it is necessary.
Tim:
And make sure you document it. Yes. One of the questions that we had earlier, was about patient delivered partner therapy. Is that a thing?
Treeny:
It is only a thing for chlamydia, for heterosexuals. And there are guidelines on patient delivered partner therapy on the sexual health STI Programs Unit website. And again, I think that has been put in the chat, but it will give you all the documentation, all the legal requirements you need, but it is a thing, but only for heterosexuals who have chlamydia.
Tim:
Thank you. And Lawrence, what are your comments? How do you do contract tracing or advice?
Lawrence:
So, look I put most people through to either Better to Know or Drama Downunder, and I just either ask if they want us to do it together or if they are happy to do it by themselves, and I guess that is a little bit in the patient’s court, and it is obviously dependent on the different STI, you know, something that potentially has greater ramifications then maybe we would do in conjunction with a sexual health service like Treeny’s, but for things like chlamydia and gonorrhoea, I would mostly direct people to those two websites.
Treeny:
One question that I often get asked is, how can you be sure that somebody has done it? We do not check up on them. We tell them why it is necessary, why it is good to do it. The majority of people will do it, very few people will not. But it is not our job to be the police here. We do not need to chase them up, make sure they have done it. Often they cannot remember their contacts if it was anonymous sex. That is okay. You just do the best you can. That is it.
Lawrence:
And you have to trust them to you know, say who those potential people were, right, so there is an element of faith.
Tim:
Absolutely. The next slide shows some of the resources that we have referred to tonight. So, Sexual Health Info Link is excellent. The Australian STI Management Guidelines as Treeny said, is really useful and really updated. I go to those all the time. They are fantastic. ASHM, particularly good for blood borne viruses, HIV. New South Wales Health STI/HIV testing tool we talked about. Also worth remembering the health pathways in your area will often have really good advice. It is localised to where you are working. We have not mentioned it now, but PrEP Access Now is a website that helps people get access to PrEP. If you want more information about that, go to some of the PrEP webinars that we have run in the past, which go into a bit more detail on that, and there are a few webinars with going into some of the sexual health issues and PrEP particularly. And also we have done some podcasts with some excellent young people talking about their experiences and what they would like to see in primary care, which echo a lot of the messages that Miriam has been telling us from the young people who were telling her what their experience was, too.
Thank you very much. I would invite you all to, those are our learning objectives, it would be great for you all to think about what you have got out of tonight and what you will do in practice tomorrow with your patients regarding their sexual health, and looking for STIs tomorrow.
Treeny:
And we can all practice. We can all practice taking sexual histories on our children, haha, and parents and friends and family.
Tim:
Absolutely. Practice will definitely make us better at doing this. So, if you ever meet anyone on the webinar in the supermarket, you know what you have got to ask them. Lawrence, Treeny, Miriam, any final comments or take home messages?
Treeny:
If there are any outstanding questions, just get them to Sammi, and we can answer them offline. So I am sorry if we did not get to your question this evening.
Lawrence:
I would say, have a look at the chat and some of the things that Timmy has put up. They are all really good references and guidelines. ASHM and the STI Guidelines have made it really easy to understand, and some of those ASHM decision-making tools, honestly, they make this stuff really, really easy to do. It is really well thought out. So, give them a read.
Tim:
Absolutely. Miriam, what is your take home message?
Miriam:
The young people I spoke to, they really did not know where they could ask questions about sex and sexual health, so if a GP can be one of those places, it could be amazing. Or even just if you could refer them to that Play Safe website, that has all the answers. I think young people really need this information, but they do not know where to get it. So it is really important.
Tim:
I think that is a great point. That could actually make a really big difference to people, just by recognising that they want that information.
Thank you very much for all your questions. As a result of your enthusiasm we have run slightly over, but really appreciate that. Thank you very much, Lawrence. Thank you very much, Miriam. Thank you very much, Treeny. And thank you, Timmy, behind the scenes and to Sammi for running the technology as well and hosting us. It has been a really good evening. I will let you all get back to your families and practice your sexual health histories with your families.