Jovi Stuart
So welcome everyone to this evening's webinar, Tips and Tricks to Encourage Sexual Health Testing in Your Practice. We are joined by our presenters, Dr Treeny Ooi, Dr Andrew Knight, Dr Kym Collins and Anna Danyushevsky. My name is Jovi. I am your RACGP representative for this evening. Before we get started, 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, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online tonight. For me, I am joined on Cammeraygal Land on Sydney's North shore.
I would like to formally introduce to you our speakers for tonight. Dr Kym Collins is a staff specialist in VMO in regional, publicly funded sexual health clinics on the mid-north coast of New South Wales and in Albury, Wagga and Griffith. Although Kym started her career as a GP, she is painfully aware of the realities and time constraints and passionate about supporting GPs to do sexual health more efficiently and confidently. Dr Andrew Knight is a senior staff specialist in general practice at the Primary and Integrated Care Unit of the South Western Sydney Local Health District. Andrew is a conjoint senior lecturer in the Faculty of Medicine at the University of New South Wales and Western Sydney Uni. Dr Treeny Ooi is a director and senior staff specialist at the Northern Sydney Sexual Health Service. She is a senior lecturer at Sydney Medical School, University of Sydney and is a keen taxidermist. We have got Anna Danyushevsky who is a coordinator and member of the Peer Education and Youth Advisory Committee for the South Eastern Sydney Local Health District, and is currently studying public health at the University of New South Wales. Welcome to all of our speakers this evening.
I would like to go over the learning objectives for this evening. By the end of this online activity, you should be able to increase GP confidence in offering and responding to requests for sexual health testing, describe guideline-based testing and advantages of utilising in practice, and identify and discuss strategies to reduce perceptions of stigma and encourage patients to feel comfortable when testing. I would like to hand over to Andrew to start off this session for this evening. Over to you, Andrew.
Dr Andrew Knight
Thanks, Jovi, and great to be with you all tonight. I am sitting here in Glebe in Sydney on Gadigal land. I had not realised that Treeny was a keen taxidermist. I am going to resist the temptation to ask you questions about that, Treeny.
Dr Treeny Ooi
I am happy to share, Andrew.
Dr Andrew Knight
That sounds extremely interesting. We are going to do some questions at the beginning to get you thinking and also so that we know where you are standing at the moment. We have got a few questions and Jovi has got the pile up there. First question, how comfortable are you offering sexual health testing in your practice? Okay, you have got five choices there. Just click on one of those and we will see some results in due course. You will get an idea of who else is here too. People are thinking. Okay. There is a pretty good degree of comfort. There is some discomfort and some people are neutral. That is interesting. Hopefully, there will be something for everybody out of this, no matter where you are.
This next question is about a patient in their early 20s who is travelling, comes to you for travel vaccinations because they are going to Bali, so a person like this, would you offer STI testing at that point? You have got four options. Yes, I would in that consult even though I probably would struggle to squeeze it in. Yes, but would offer a follow-up appointment to do it. Yes, but suggest they do it when they get home or no, only after taking a sexual history. What would you do? Okay, 42% saying I would take their sexual history first before offering screening. About a third of the people would actually just offer a test straight off. 12% are doing a follow up and 11% are doing it afterwards. It will be interesting to see where you sit with some of those thoughts at the end of the session.
All right. Next question. A male patient attends and that person says they have got pain when they urinate. He states that he has sex with men and women. What specimens are recommended to collect for testing? Just choose one of those. According to your knowledge, what specimens would you be wanting to collect to test this person? Urine only, urine, anal, throat swab, urine and bloods, all of those listed above and treat syndromically? What does treating syndromically mean? Sorry. Can someone explain that quickly?
Dr Treeny Ooi
It's Treeny here, I can. Do you want me to explain it?
Dr Andrew Knight
Very briefly, yes.
Dr Treeny Ooi
Okay, so if they come in with symptoms of an STI, then you treat according to your local epidemiology to what you think is the most likely thing. If they come in with dysuria or discharge, which is clear or mucoid, you might treat them for and they only have sex with women, then you probably treat for chlamydia. If they have sex with men and women, then you may treat for gonorrhoea and chlamydia.
Dr Andrew Knight
Okay, so syndromically means according to the clinical context.
Dr Treeny Ooi
Exactly right.
Dr Andrew Knight
Okay. Here are the options. Not many people are just doing urine. A lot of people are doing everything. About a third are doing them all and then treating syndromically. Okay. Great. That gives us some ideas.
Here is another one. A male Colombian student who has sex with men presents at your practice, never tested for STIs, and his reason for testing is wanting to start HIV pre-exposure prophylaxis or PrEP. What do you do? Three options. STI, HIV testing only, test as per the ASHM PrEP guidelines, and then supply a prescription at that moment or refer to a sexual health clinic? Let us be realistic. What do you truly do in your practice? Most people are testing, according to the ASHM PrEP guidelines. About a third of people are actually referring to a sexual health clinic at that point, and then some people are just doing the STI, HIV testing. Again, I think by the time we get to the end of this, you will have some ideas about where you might go for information about that. In the spur of the moment when you have got a question, perhaps we do not feel confident with or a situation we have not come across before. As Wei Cheng says, not familiar, so I refer on, not unreasonable. Part of the point of this webinar is hopefully you will have some resources that you can turn to quickly to move through. Thanks for that. The point is to just get us all thinking, get us in that frame of mind and that context of what we are dealing with tonight. The whole question of sexual health testing in our practices as people come to see us, making sure that we are doing the best for our patients and the community as those patients flow through our doors. We are now going to move to a time where we actually look at where we are. It is constantly changing the context in which we practice, the epidemiology which we face. The epidemiology you face in your practice is going to be different to everybody else's. We are going to work through the current epidemiology of STIs in New South Wales. We are going to be led through that with some data. I think I am going to hand over Treeny. Fantastic.
Dr Treeny Ooi
Thank you very much, Andrew, and thank you everyone for joining us this evening. I am going to present some data and then Kym will present some data also. This is the chlamydia data. Chlamydia is the most commonly notified STI in Australia and New South Wales is a part of that trend. You can see here that it is very, very prevalent particularly in young people. Both males and females are young peoples, so we are talking about less than 29 years, although as a middle-aged woman, I would say less than 55 years maybe. Anyway, anyone who is sexually active can be at risk of chlamydia. You can see here that when we consider the overall trend of chlamydia in New South Wales, there is an overall increasing trend. Now there is a dip in 2020 and 2021, and that's a result of COVID and decrease in testing and also changes to social distancing, fear and people's sexual activity. Overall, we are back to the numbers that we have seen prior to COVID and they are continually increasing.
Let us move on now to gonorrhoea. Gonorrhoea is the same. We had a decrease in 2020 and 2021 associated with COVID-19, but overall there is an increase. That's a little bit sharper than the chlamydia increase. Now, gonorrhoea is most common in men who have sex with men and it is common throughout all age groups. You can see the increase, and that may be partly explained by the fact that there is a lot of unprotected sex happening. We are talking anal sex as well as with heterosexuals, vaginal sex, also oral sex and the prevalence of unprotected anal intercourse may be partly due to PrEP, so people are worried that they are at risk of HIV, so increases in STIs is something that you may see in your practice. The issue with gonorrhoea and chlamydia, of course, is that both of them can be asymptomatic.
New South Wales HIV data, and this is true for all of Australia, is looking pretty good. Apart from the fact that we are seeing decreased diagnoses, we are still seeing a reasonable and a significant amount of diagnoses occurring in general practice. These are general practitioners who are non-s100 prescribers. S100 prescribing is HIV antiretroviral prescribing. These are GPs like most GPs are who do not have specific HIV prescribing qualifications, which may mean that they do not have a large HIV cohort and have not done the s100 training. The data is looking pretty good as I mentioned. There is a slow decrease in HIV diagnoses overall, we are seeing the decrease mostly in Australian born men who have sex with men, but for overseas born men who have sex with men, it has not decreased as effectively as in Australian born. This may be the fact that overseas born MSM, particularly those who are in Australia less time than others may not be aware of health systems and may not have access or be aware of their access to HIV pre-exposure prophylaxis.
This is a little bit more data breaking it down into sexual risk or sexual orientation. Men who have sex with men, you can see here there is an overall decrease, but we are seeing there was a little bit of an increase after the COVID-19 back to normal era. It is less of a stark decrease with heterosexuals and other groups who have put that down as their sexual risk.
Dr Andrew Knight
Can I ask you about HIV. I am not sure if this is the right point, but I think your point that a lot of the diagnoses are being made in mainstream general practice. I think it is really important for us to be aware that we will be doing it. It will not be often, but we need to have that on our radar as something can still happen.
Dr Treeny Ooi
That is quite right, Andrew. It is really important to test for it. HIV testing is very cheap. It is very easy. You can add it to any serology request. There is no requirement for pre or post test counselling. You just need informed consent. Just on that point, the majority of STI diagnoses are also made in general practice. Only a very, very small percentage, around 8% are made by sexual health clinicians. The majority of STI diagnoses, both gonorrhoea and chlamydia are made in general practice and a significant amount of HIV diagnoses also.
Dr Andrew Knight
Yeah. I am not sure if we are covering it later, but one of the fantastic things about New South Wales is the follow up process that if you do make a serological diagnosis with one of one of our patients, we will be getting a call and support to manage that person optimally. Even though it is something we are not necessarily familiar with, there is heaps of support.
Dr Treeny Ooi
Exactly, so there is an HIV support program, which I will speak about towards the end of the webinar. Nobody is allowed to go off.
Dr Andrew Knight
I am glad I have mentioned it now. That is good. Okay. Thanks a lot, Treeny. That is fantastic.
Dr Treeny Ooi
Thank you.
Dr Kym Collins
Yes. They have to stay on. There is lots more exciting stuff to come. My name is Kym Collins. I am beaming in from Darkinjung Land around Gosford. I get to talk with you about syphilis, which is actually my pet subject at the moment because the LHD I work with has been declared an outbreak area for syphilis, and we are seeing a lot of infectious syphilis. As Trreny said, with the HIV diagnoses, a lot of these diagnoses are made by GPs. Syphilis is a great pretender. We have got little video snippet. The orange colour within this graph says infectious syphilis. That means that it is very easily transmitted. It also raises the spectre and concern around congenital syphilis, particularly for women of reproductive age. The older kind of diagnoses of syphilis are remaining fairly steady for syphilis.
Can you do the next one? This is of particular concern. This is syphilis in women of reproductive age. These are the notifications of women in reproductive age by pregnancy status. You will see the light teal colour is women who are pregnant. You can see inexorably over the years in the last decade, there has been an increase in numbers, and you can see in 2022, there were 24 cases of women whose infectious syphilis was diagnosed during their pregnancy. You can also see in non-pregnant women, but still women of reproductive age, so then obviously potentially could be pregnant. Again, inexorably those numbers have increased. Syphilis is about it is a great pretender. We are going to have to test our way out of this. In fact, Kerry Chant, our New South Wales Chief Medical Officer has requested that all women receiving antenatal care, no matter what their perceived risks are, should be screened for syphilis at booking in and also at 28 weeks at least. In some areas, like the mid-north coast where I work, we are doing five lots of syphilis screening because we are an outbreak area.
Next slide, Jovi. This is the stuff that is really upsetting. I had a case today that I have been chasing for most of the day. A young woman pregnant, which is probably going to be our first case of congenital syphilis. She has not had syphilis serology done until 34 weeks. She has an RPR of 64. You can see, again, we have had sporadic cases, but I think we are going to see more because I think we have still got a way to go, and the role of the GP in terms of testing for syphilis, particularly in the context of antenatal care, because you guys have ongoing relationships with these women, it is vital. The more you screen for syphilis, the better, and at least twice during the pregnancy.
Next, I think next is the video. I will hand this over to Jovi. This is our Chief Medical Officer, Professor Paul Kelly, speaking about the syphilis outbreak and the issues around congenital syphilis.
Professor Paul Kelly
Any baby losing its life is a tragedy. Any baby losing its life to a preventable illness is a responsibility for us all in our health system. Syphilis cases are on the rise in Australia, including among young people of reproductive age. As a result, we are seeing the re-emergence of congenital syphilis when the infection is transmitted during pregnancy. This can have devastating health consequences for newborn babies, including death. Congenital syphilis is also entirely preventable. We must ensure everyone is tested for syphilis during pregnancy. All pregnant people should be tested at least once and in many cases more. Check your state and territory guidelines for details on additional testing. Once diagnosed, treatment is simple and effective. As cases rise, it is our responsibility as health professionals to learn more about syphilis testing and management. ASHM now has a range of resources, guidelines and training at ashm.org.au/syphilis to support you to play your part in the fight against congenital syphilis. A resource I especially want to draw your attention to is ASHM's online syphilis decision making tool. It is a simple, comprehensive, and easy to follow guide to syphilis treatment in common clinical scenarios and can help you decide the best treatment for your patient. I have used it to make sure that I am up-to-date. Why do not you? Together, we can prevent the needless deaths of any more newborn babies from congenital syphilis. I thank you for your assistance.
Dr Andrew Knight
Okay. Brilliant. There is a link for you.
Dr Kym Collins
It is a call to arms for all of us, and ASHM stands for the Australasian Society for HIV Medicine, and they are very proactive in the space of blood-borne viruses and STIs. There are some really good resources that you can use on that site, so save that link. The other thing that is invaluable is the Australian STI Management Guidelines. If you had one tool as a GP that you used, digital tool, it would be this one. In a few slides, we will take you through how to use it and we will talk a little bit about syndromic management as well, so that will key in with Treeny's earlier comments.
Dr Andrew Knight
Thanks, Kym. I think that is really helpful to hear all that about the really central role we as GPs can have in very important interventions. It is great to be reminded of that. It is great that you guys have given up your Monday night to think about this and to increase your skills and increase your knowledge in this area because it is an area where we can make a real difference. It is really important for our patients. Here are some clues for helping us when we are in practice and that flow of patients is going past us. Where should our attention be? Who should we be asking? You have got to have that index of suspicion and be willing to ask the questions. That is some of the things we are going to talk about today. Here are some of the groups that you might like to think about. When people from these groups are sitting in front of you, obviously you need to ask and think about sexually transmitted illness screening. Some of them, I guess, seem obvious. It is good to be reminded. One thing that strikes me is regional and remote populations. Can I just ask Treeny or Kym, are people from regional and remote populations particularly at risk of sexually transmitted illnesses? Why are they listed as one of the groups here?
Dr Treeny Ooi
I think one of the main reasons, Andrew, is because there is less access to health care or access to services. In regional and remote areas, often there is only one GP, so there are real confidentiality issues. It is not that the GP has issues with confidentiality, it is that the person feels that they are not comfortable in saying anything because it might be the family GP. If I was in a relationship and I went to the GP with my partner, then I might be fearful to say, or for whatever reason, or embarrassed to say that I had other partners. There is also people who may be married who have sex with others of the same gender to themselves. I may be a married man, and I may be having sex with other men, which is not known to anyone. There are real concerns for me about disclosing that information.
Dr Andrew Knight
Yep, sure. Treeny, are there any other points you want to make about this sort of way of thinking, the index of suspicion?
Dr Treeny Ooi
I think it is really important to conduct a sexual health screen if somebody asks for it. I see patients who come in and say, "Oh, I went to the doctor and I asked for an HIV test, and they said "Oh, you don't need that". Or I asked for an STI screen and they said "Oh, you don't need that". I think it is really important that if a patient asks for it, then we do it because there may be a lot of things that they are not telling us and that they will not tell us for whatever reason, nothing to do with us as medical practitioners, but it might have something to do with them and for whatever the concerns they may have. If somebody asks, I think, you do that regardless of what my opinion of their sexual behaviour. Whether you have sex with men, whether you have sex with women, whether you are paid for sex, we do not know a lot of what people's private lives are and even though I work in a sexual health clinic, I am well aware that people do not tell me everything or they may be telling me something that is not completely accurate. I think it is really important to keep that in mind.
Dr Andrew Knight
Sure. I guess it is their partners as well with all these groups. If you are seeing a partner, you may need to…
Dr Treeny Ooi
Exactly, right.
Dr Andrew Knight
Okay. Well down the bottom there you will see young people…
Dr Kym Collins
Often people do not know what their partners are up to.
Dr Andrew Knight
Yeah. I think sometimes it can be hard to broach the subject. I think as GPs sometimes we wonder how people are going to react when we raise the subject. You have got any thoughts or comments about that?
Dr Kym Collins
I would say I think it is just important to normalise it. We do this for everybody. This is just routine testing and just take away the stigma and the discrimination. Often people are quite relieved when you actually ask them the questions because they are concerned, but like Treeny said, it is challenging for them to have the language and the confidence to bring these things up often.
Dr Treeny Ooi
They have done some research with GPs and with patients of GPs, and they have found that patients are not embarrassed. They are not insulted when their doctor asks them, would you like a sexual health screen or an HIV test? They would prefer that, and they think their health professional or clinician is being professional and thorough, so patients actually welcome the opportunity to have a test.
Dr Andrew Knight
Incredibly helpful research, Treeny. Thanks for that. We often do not know what our patients are thinking, and it is hard to know what our patients are thinking. We actually have a real privilege tonight in that we are joined by a consumer representative from a consumer group. Anna is going to join us. Are you there, Anna. There you are. Great. Thank you. This is fantastic. I said to Anna before, we very rarely get this opportunity as GPs to actually do a consultation and say to the person afterwards, how did I go? What did I stuff up? How could I do better? When time is of the essence, and also it is just difficult to do. Thank you so much for joining us and being willing to be in the hot seat with hundreds of doctors looking on. I hope that is okay and you will feel okay. You are very welcome. You are the absolute expert in this area. We do not know, although we are patients, but we do not know in the way that that non-doctors know what it feels like to go into a consultation, especially in these very sensitive sort of matters. You have been listening to that. Could you introduce yourself and just I would be interested in your advice, having heard some of the talking about how would we talk to people, what would you say to us? What would you like to say to us?
Anna Danyushevsky
Thank you Andrew, and hi everyone. It makes it a bit easier that I cannot see you all and all your faces. My name is Anna. I am part of the Peer Education Youth Advisory Committee for South Eastern Sydney Local Health District. We do a lot of peer education out in community around sexual health and also other youth health issues around vaping and alcohol and other drugs and things, but we get a lot of feedback from the community around young people and their experiences with sexual health and how much they know and how comfortable they are in getting STI tests at GP. I have spoken to my committee which is a group of diverse young people from age 16 to about 24 about their experiences as well going to see GPs and I think the main takeaway from a lot of it is that especially for the younger young people, let us say teenagers, or if it is the first time they are going to get an STI test is that we really want to feel validated in that whole experience. STI testing us coming into it is very frightening. We know that STI is a stigmatised and all of those things, even the step of just booking an appointment or getting ready to say like, could I get an STI test that already getting to that point has been such a big build up for a lot of young people. Regardless of even what the issues are, usually we let it build up a lot before we see a GP, unless it is something, you know, very urgent and we are in pain or there are symptoms, we usually let health issues build up a lot. I do not know if you have had this experience before, but we would have usually on our phones, just write a list of issues and just throw them all at you all at once, and it comes from that place of we are a bit scared to start that conversation and initiate it, so I suppose having GPs understand that is what we are coming in with, and especially young people for the first time coming in with an appointment can be probably quite helpful for you, and maybe having us feeling like we are heard and that these issues even though they may be frightening, they are actually not issues. They are not scary having just those key messages, which may seem easy to you to say, STI is a very common or I do so many STI tests, there is nothing to worry about. Those blanket statements to make people feel very comfortable is always great. Having education in trauma and knowing how to speak to young people around their sexual history and experiences also helps as well. I think the main thing is just making us feel heard. A lot of the times and a lot of feedback we get which is understandable from GPs, and how busy you are and how many appointments you have, but that usually we do not seem as especially, let us say, if we are getting an STI test and we do not have symptoms, it does not seem like an importance, so having that validation that we have made the step to come here, it is a really big point. If it is the first interaction with a GP and it is not a good one, we are not going to come back, and that is a lot of what we heard, and I think it is just making us feel comfortable letting us know it is not scary, and then just providing extra information, so maybe also do not assume that we know everything. We may see a TikTok or see online something on social media of what we think is true, but we may not actually know what an STI is, so explaining to us, maybe if a test does come back positive, what that means. How easy it is to treat all of those things I think are helpful. I throw a lot in there, but happy to answer any other questions as well.
Dr Andrew Knight
That is great, and I really appreciate that. I will just remind everybody that the Q&A is there, and if you have got particular questions that you would like to ask, you can throw them up there, but that point about validating, it is great that you have come, it is important question. Yes, we will try to answer, and that really normalising it. This is common and yes, we can do this, we do this all the time, and it is great that you have done it. I really appreciate that. So we will keep moving along, and I think we have got some resources to look at. Treeny and Kim, is that right? It might help in this area.
Dr Treeny Ooi
That is right. There are a few videos just to show people how easy it can be to do a sexual health screen.
Dr Andrew Knight
Fantastic. We are going to actually have some videos. The way this is next bit is going to run is we have got a consultation on video broken up into little bits. We are going to look at it and then we are going to discuss it, and we have got the panel to give some advice and thoughts about all of that. Jovi we are going to go straight into that. Here we go.
GP
Hi, Alicia. Nice to see you again. How are you feeling?
Alicia
Mostly okay, but I have just come in because I have got this rash on my arms and my legs.
GP
Let us have a look. All right. There are a few things that can cause a rash like that. Can you tell me a bit more about it?
Alicia
Well, it is only on my arms and legs, but it has been here for about a week now.
GP
And have you noticed any other skin problems recently?
Alicia
Well, now that you mention it, I did have this ulcer in my mouth about four weeks ago.
GP
Oh, sure. Can you tell me a bit more about that?
Alicia
Well, it was not very painful, and I thought it was because I bit it, but I do not remember doing that, and it was there for about a week, but it is gone now.
GP
Good to know. Thank you, and how are you feeling generally in yourself at the moment?
Alicia
I did notice in the last week, I have had some headaches, and I have been getting a bit hot and cold, and I did feel like I had some glands up around my neck and around in my armpit. I am not sure what that is about.
GP
Okay. Have you had any changes in your environment recently? Like, have you been travelling or gotten a new soap at home?
Alicia
I did go to the Northern Territory about six weeks ago and got bed and breakfast quite a few mozzies, and I did change my laundry detergent a couple of weeks back.
GP Okay.
Dr Andrew Knight
Bit of a history there Anna, you sat and listened to that. Any comments or how would you advise us on that crucial moment of taking a history?
Anna Danyushevsky
I think this is a good scenario as well, where I do not think the young person knows what they are coming in for, so I think what I enjoyed about that scenario was that the Doctor was not immediately heading towards it is an STI and setting off alarm bells and that sort of thing. They were still sort of taking the history, getting all the information, but not making it very obvious. They were just like, yes, that is fine, a rash there and also there just written no major reaction to particular answers I think can be quite helpful.
Dr Andrew Knight
To be fair, when someone comes in with a rash on the legs, it could be so many things. The could have flares, so it is interesting to see the way that consultation starts to home in. I can see what you are saying. It is very calm, very generic, but asking the questions. Treeny, Kym, got any comments that you want to make?
Dr Treeny Ooi
I think one comment that I would like to make with that video is that the doctor was engaged, listened to what the what the client was or patient was saying, open body language, so was nodding, and there was no judgement. Language use was really neutral. Those are really key issues, I think.
Dr Andrew Knight
But young person the age group, the antennas are up, are not they, could it be an STI, and I think that is important. Now, we have got some resources to show because if it is going through your mind what is happening here, I think Kym, are you going to show us this? Is that right?
Dr Kym Collins
Yes. We just want to showcase the Australian STI management guidelines for you all and give you a bit of familiarity around using it. This is a really excellent resource. You can stick on your desktop, and I have got control now, I think, or I meant to have. If, for example, you have got someone who presents with anogenital lumps, you can check under syndromes. You can actually check under STIs. You can look warts, chlamydia, donovanosis, etc. You can look at populations and situations, and we mentioned that recently, and for example let us go through to syphilis just to give you an example. Sorry I will have to scroll down there. I am just going to let me do that. It looks like it. Yep. There you go. Okay, so when we click on syphilis this is what you will get, and this is branded across all of this site. You can get very familiar and get the information very quickly. It goes through anything that is an overview in terms of recent stuff which can be very illuminating, and then you will be able to break down into these boxes. It will tell you what the cause is, it will tell you the likely clinical presentations. You can then go to, how you make the diagnosis. You can then skip to management, and each of those boxes will open up for you on any of those of those STIs. I think if you had to have one resource that you were going to use, this is what I direct to GPs and just get online, literally Google Australian STI management guidelines, the links actually there and just play around with it for a bit. It is a really quick way of getting the really salient details that you need when you are considering an STI or you, in fact get a result back for a positive chlamydia test or positive syphilis test.
Dr Andrew Knight
Okay. Brilliant. We have actually spent a bit of time on this because I guess, as you said, Kym, if there is one message that we love us all to get out of here, out of this this evening, is that these guidelines are available. They are up-to-date. They are excellent. You are going to be giving evidence based treatment if you click on these guidelines, and it is so quick to find the information that you need.
Dr Kym Collins
They are also updated every 6 to 12 months by a panel, so you know, you are getting accurate you contemporary information.
Dr Andrew Knight
All right, I think we are going to go on to the next part of this consultation.
GP
Thanks for all that information so far, Alicia. In this kind of situation, I usually ask some questions about STI risk because sometimes sexual infections can cause these kind of symptoms. These are questions that I ask everybody in this situation. Is that all right with you?
Alicia
Sure. If you think it will help.
GP
I think it will. Thank you so much. I can see here that your last STI test was about a year ago. Have you had any new sex partners since then?
Alicia
Yeah, I have. Okay.
GP
And when was the last time you had sex?
Alicia
About six weeks ago. I met someone up at the bar at Darwin.
GP
And can you tell me a bit more about what happened with them?
Alicia
It was just like a casual one night thing. We just met at the bar and fooled around for a little bit, and I ended up going down on him.
GP
Okay, thanks for that, and in the last six months, how many partners have you had in total?
Alicia
Maybe like 1 or 2 others.
GP
And when was the last time you had sex without a condom?
Alicia
Oh, I, like, never use condoms. I am on the pill.
GP
And what are the genders of your sex partners?
Alicia
Only men.
GP
Okay, thanks for that.
Dr Andrew Knight
Okay, so Anna I am going to put you on the spot again. I hope you do not mind. That is getting to the difficult part of the consultation where you are talking about very personal matters. Any comments on or advice that you would like to give our listeners based on that?
Anna Danyushevsky
Yeah, well, I think seeing that it was a pretty good example of again, starting off, I asked these questions to everyone. It, especially from a young person, makes you feel a bit more empowered of like, oh, you are treating me like an adult or like someone else would be, that is a great way to start. I think, as well, the fact that at least in the video, she was looking at the patient the whole time, because a lot of the times I have experienced and other peers have experienced them, they would be looking at the laptop or typing somewhere else. I think being quite present is always good. Just being conscious that it may be the first time that a young person has ever been asked these questions. They are being quite vulnerable. I think that was quite well done and not really judging any of the answers either. Just like it, I am sure it is fine. It was just something that you did.
Dr Treeny Ooi
Can I just add one more thing, Andrew? I think it was really great that there were no assumptions, so what are the genders of your partners, for example and I thought that was great.
Dr Kym Collins
The other thing that I think worked really well is that she created a bridge between why this young person had come in and why she needed to ask these questions related to her sex life, and I think that bridge or that connection is really important because people understand, and she clearly seemed to understand.
Dr Andrew Knight
I must say it took me a while as a new GP to not make assumptions. It is just so easy to do. And are there pretty direct questions? They are pretty confronting. That is okay.
Anna Danyushevsky
I think they are okay if you lead up to it. I think sometimes it is better than treating us different again from that young person view of, I am going to word it in a different way if you just sort of let her say, I gave a blow job like that, it just letting it seem normal, and that it is fine. If you start trying to tiptoe around it, the young person may just feel like Why are you being weird? Should I feel weird? Should I feel weird answering? So I think it is nice being quite direct.
Dr Treeny Ooi
And you can feel if the doctor is uncomfortable with the topic, and also the doctor asked permission. I am going to have to. Is that okay if I ask you some yes or no questions?
Dr Andrew Knight
Yeah. It is respectful. All right. Shall we move on to the next bit?
GP
Thank you so much for all of that information, Alicia. Based on your answers, I think it would be a good idea to do an STI screen to check for any sexual infections.
Alicia
Yep. Okay.
GP
So one part of that will be a blood test, and that is going to check for syphilis and HIV. You can get that done just at the pathology lab next door.
Alicia
Sure.
GP
And the other thing I would like to do, if it is all right with you, is testing for chlamydia and gonorrhoea. You will be able to test that on a vaginal swab, which you can collect yourself in the bathroom.
Alicia
Okay. How do I do that?
GP
Good question. So this is the swab. Now, do not worry. You do not have to put it all the way in.
Alicia
Okay, good.
GP
You just insert the swab into your vagina about an inch, move it around a little bit while you count to ten, take it out and pop it back in this tube and bring it back to me.
Alicia
Easy.
GP
Some things that are just important to know about, particularly for the blood tests, HIV and syphilis, there is a thing called a window period of about six weeks. This means that if you have contracted those infections in that time, the test might not show up the infections quite yet.
Alicia
Okay. Yep.
GP
So let me just check. We have got your correct contact details on file. Are you okay to be contacted on your mobile with the results?
Alicia
Yeah that is fine.
GP
Okay, great. And do just be sure not to have sex until we have those results back, just in case there is an STI there.
Alicia
Yep. I can do that.
GP
Okay, great.
Dr Andrew Knight
Okay, well, my sound and picture is getting a little out of sync there, but I think we got the message. So, Anna, I am going to you first because you are the expert. I hope that is okay on the patient perspective. So testing and explaining it. We are deliberately showing a good example, I think because it is better to show good examples and show bad examples, but I think we all like to see it well done, and we learn things from seeing people do something well, but from your discussions with your committee and, and also, your views, any thoughts, any advice you would give us on the whole testing and explaining side of things?
Anna Danyushevsky
I think it was quite well explained in terms of separating the two kinds of tests and one, you have to go to a pathologist, even though there have been experiences where, let us say, I would know that that like getting a blood test means go to a pathologist, but even just being going that bit further of saying there is one down the road, you can find it here, here is a map, just that little bit further of explaining how do you go do it? Because you just get a script at the end or whatever, and you are expected to go and suddenly do that test. So I think, it is definitely good to go into a little bit more, and in that example the young person says, what does that entail? But for the most part they usually do not. You would be too scared to ask or maybe you, I do not know, think you could Google it. I think in that example the patient did ask of how does the vaginal swab work? I think maybe even asking, have you done one of these tests before? Do you know what to expect and just prepare them, taking that extra 30 seconds or whatever it may be to just say, this is what the test looks like, this is how you do it. It can be really valuable with it. Overall was a good example, but I think just going into more detail than you would think, you would have to.
Dr Andrew Knight
Yeah, that is really helpful. We do this sort of stuff every day, but the patient does it, how many times in a lifetime, not that many. It is really helpful to be reminded of that. It is easy to forget. Treeny, Kym, any comments? I am just conscious, we need to keep moving, but I want you to have an opportunity to give us any thoughts that you may have.
Dr Treeny Ooi
One quick comment is that the patient can collect it on the spot and take it with them to the pathology, and that way you know that it is done.
Dr Andrew Knight
Good thought, Kym.
Dr Kym Collins
Yep, I agree. Okay, I better move on.
Dr Andrew Knight
Yeah. Let us go to the next video.
GP
Hi, Alicia. Thanks for coming back in today.
Alicia
Yeah. No worries. I am a bit stressed that you have called me back in.
GP
So look, the reason I did call you back in is because the test results show that you do have a syphilis infection, and that will explain all the symptoms.
Alicia
Really? That is so embarrassing.
GP
It is really normal to feel that way. Do you know much about syphilis?
Alicia
No, nothing at all. Is not it like a disease from the past? Like no one has syphilis now?
GP
Again, it is really common to feel that way, but let us talk this through together, and it is going to be okay, all right?
Alicia
Okay.
GP
So, syphilis, it is a bacterial infection, and it is something we can cure completely with some injections of penicillin antibiotic for you.
Alicia
Oh, okay. I am not a fan of injections, but if that is what it takes to get rid of it, then I am relieved.
GP
Yeah, no one loves injections, unfortunately, but it is the best treatment for this kind of infection, and like I said, after that, you will be cured completely, although you must not have sex for seven days after the injection because it takes that time to work.
Alicia
Okay. That is doable. What else do I need to do?
GP
We do need to talk about contacting your sexual partners from the last six months.
Alicia
Oh, really? You have to. That is so bad.
GP
Sure, it is really normal to feel that way, but it is really important so that they can get tested and treated. They can stay safe, and also so we can help stop the spread of this infection through the community.
Alicia
Okay. I guess, how do we go about that?
GP
It is pretty common to feel embarrassed about having to contact people. There are actually some websites that can help us do that anonymously. Can send an anonymous text or an email.
Alicia
Oh, that is great, but the person from Darwin, I actually do not have his number or email. He just sent me a friend request after, but I ignored it.
GP
That is a little trickier, but there is a special service called the Sexual Health Info link, and they can help us contact him over Facebook to let him know.
Alicia
Okay, and they will not say anything about me, like he will not know who it was.
GP
Definitely not. It is completely anonymous.
Alicia
That is really good.
GP
Yeah, it is really great. The other thing we do need to do is just to make sure that the treatment has worked, I will need you to come back and do that blood test again in three months, six months and again in 12 months.
Alicia
Yeah, I can do that. That is easy.
GP
If you would like, I can help you fill out that form for the sexual health info link now before you go.
Alicia
Yep. Let us do it.
GP
Okay. Why do not you pull up his details on your phone and I will get the website up and running here.
Alicia
Great.
Dr Andrew Knight
Okay. Great. Anna. Comments. Advice.
Anna Danyushevsky
I think the only thing I would add to that is that there was quite a lot of information thrown at that young person, so writing it down, having a list of you need to do this, then this, then this, and then using that, maybe to give extra resources or other things around what syphilis is or how it can be treated. I think there is a lot of reliance of that person remembering what they have to do, and then they have to go and get treated and remember to book back an appointment, so, having it written down or something or making sure they write on their phone with you there, would be great.
Dr Andrew Knight
Fantastic. So, Kym, I think you are going to actually share a couple of those resources. I am conscious we have only got five minutes left, so you will need to be quick.
Dr Kym Collins
Okay. So very, very quickly. I would say I often use the young person's mobile phone when they are in with me. I will actually take them to the let them know site, which is the one that we most commonly use, and the link for that is there. They can do anonymous contact tracing through that. If you do not have a mobile phone, you can do it through the sexual health information link, and the website is down there as well, but again, that that is a way, and you can just document in your file, three casual male partners contacted via let them know, so for chlamydia and for gonorrhoea that is great. For syphilis, I tend to do, I think the practitioner should be doing a bit more of the contact tracing, but that is a whole other conversation and we are running out of time. So. I will leave it there.
Dr Andrew Knight
A few people are asking about those resources. So that is fantastic Kym, and then Treeny, were you going to mention the HIV support program?
Dr Treeny Ooi
I was, so the HIV support program, I think we will just miss the poll, but the HIV support program is, if you are a GP and you make an HIV diagnosis, then there is an HIV support program coordinator in each local health district in New South Wales. If you opt for support, then if it is in my district, you will get a call from me at the time that you prefer, and I will say, what can I help you with? Do you need resources? Support? Do you need me to give the diagnosis or somebody that in my clinic? Do you need a referral information? Any way that I can help you, I will, and that is available throughout New South Wales. Once you make the diagnosis, if you prefer, it can be completely out of your hands.
Dr Andrew Knight
Brilliant, and look that at that video I thought was excellent. There are a couple of other videos if you would like to watch them, if that is your style of learning. There are some resources there that you can look at, and I think we are almost done guys. I just want to go to each one very quickly in one sentence. Does people have takeaways? Treeny, Kym, Anna, that you want to just say to people as a last chance before we wind up.
Dr Treeny Ooi
My main takeaway is that there are lots of available resources for General Practitioners in New South Wales. If you go on to the STI Programs Unit website, you can get checklists, posters, anything you need. The other thing to do is you can contact the sexual health clinic in your LHD. There will always be at least one. If not, there is still the support line, and that will come up, I think it is in the next slide.
Dr Andrew Knight
Okay, Anna, I am going to give you the last word.
Anna Danyushevsky
I would just say to all the GPs, be confident in it. Yeah, definitely. It is a really sensitive topic and young people, but I feel like anyone, if your doctor does not feel confident in helping you, you are going to match that energy. I think having resources for yourself is helpful, but even just handing out resources to us is better than nothing, and just not going into that detail. If you do not know, just send out a fact sheet, that is fine as well. So, yeah. Be confident.
Dr Andrew Knight
Okay, and thanks to you, Anna, for being willing to be here to help us, and I think we are just about done. I am sorry. Kym, I have cut you off. Is there anything you wanted to say?
Dr Kym Collins
I was just going to say that life is a sexually transmitted condition, heaven forbid. Most people have a sex life. The more you talk with people and the more comfortable you get with sex, the more kind of comprehensive care you can give to your people and your practice.
Dr Andrew Knight
Fantastic. All right, over to you, Jovi, to finish things off.
Jovi Stuart
Thanks, Andrew. I would like also like to thank all our speakers this evening, Andrew, Treeny, Anna and Kym and everyone else that have shown us online tonight. Hope you enjoyed your session. Just a reminder that as this is a CPD accredited activity, you will be allocated your CPD hour once you have completed the survey following this webinar. If you have missed any part of this recording, it will be uploaded on the RACGP website in the next week. We will be sending through a copy of the slides to your email tomorrow morning. Thank you everyone. Good night.