2018 European guideline on the organization of a consultation for sexually transmitted infections

Abstract

Dr Keith Radcliffe. This is an update of the 2012 IUSTI guideline. In this new version, we have expanded the sections on sexual history taking to include PEP and PrEP use, intimate partner and gender-based violence, chemsex, swinging and psychosexual problems. We highlight the potential for the use of technology in the context of sexual health to facilitate sexual history taking and partner notification. We have explained the principle of safeguarding young and other vulnerable people who may present to services. This guideline is primarily aimed at services provided in mainstream clinic/office environments, but increasingly many countries are seeing an era of rapid transition of sexual health services in which satellite clinics and online service provision are centre stage. Services are moving away from the main hospitals/clinics into smaller peripheral sites and various non-traditional or outreach type settings such as saunas, brothels, bars, clubs, educational facilities, prisons and gay pride events. The advantage of such services is that it might allow hard-to-reach groups to be engaged with clinical services.1 We need a cohesive, multiagency approach to addressing the challenges associated with this style of service provision, if we are to harness the potential for decentralization of sexual health services while safeguarding the most vulnerable and remaining true to the founding principles of sexual health care. The following staff groups are essential in the smooth running of a facility managing patients presenting with sexually transmitted infections (STIs). The following staff can provide additional services and benefits to such a clinic Pathways for referrals to involve other specialists may be required depending on local service arrangements – for example paediatricians for concerns over paediatric and congenital STIs. Safety of staff should be considered in all settings. Consideration should be given to use of panic and personal alarms, minimizing lone working, and use of accompanying colleagues for patients who are known to display aggressive behaviour. Local reporting practices for incidents or near misses should be followed. The particular vulnerability of patients attending a clinic that tests for and/or treats STIs demands strict confidentiality. Services should explain how patient information will be managed and shared, and on what grounds confidentiality might be breached. When taking a sexual history in a non-confidential environment, encrypted devices should be considered for recording sensitive patient information. The writing group recommends that healthcare professionals delivering a sexual health service should be familiar with the ethical and legal frameworks on safeguarding adults and children, consent and confidentiality. Safeguarding involves protecting people's health and human rights to enable them to live free from harm or abuse. It involves making an assessment of factors which could make someone vulnerable to such harms, and instigating measures to reduce these. Pathways to support these assessments and procedures will vary according to local practices and legislation. It is good practice to obtain consent to share information with general practitioners (GPs) or family doctors, where the diagnosis or procedure may have longer term health implications.2 All attempts should be made to maintain patients’ dignity, allowing them to dress and undress in privacy, and only exposing areas as necessary to examine them. A chaperone should be offered for all intimate examinations, to reassure the patient, act as a witness and assist in the examination and performing of any investigation. This offer should be documented, along with the name of the chaperone, in the medical record.3 Consent for any other staff in training to be present in the consultation should be ideally sought before the patient enters the room, to ensure they do not feel under pressure to comply. The staff member should be certain that the presence of such a trainee/observer will not affect the patient's care.3 The patient's sociocultural and religious values also need to be taken into consideration when delivering a sexual health service. Social, cultural and economic factors can all affect sexual desire, attitude, behaviour and practices. Therefore, addressing these factors in a globalized society is extremely important. Minority groups need to feel comfortable with, and have trust in, healthcare services and the professionals they encounter. Cultural sensitivity in the patient–provider relationship should enable culturally diverse patients to experience patient-centred health care, which is relevant to their needs and expectations.4 History taking should be done systemically with more sensitive questions being left until later. Structured proformas can be used to document key history and examination findings, and subsequent investigations and results. However, it is important not to see the history taking process as a routine, but to remain able to adapt to the patient and clinical situation. When taking a sexual history, the healthcare provider should modify their language to ensure it is comprehensible to the patient. This will often mean avoiding medical jargon and instead utilizing sexually explicit language with which both the patient and the clinician are comfortable. People presenting to sexual health clinics vary in the complexity of their presentation. Some present asymptomatically for routine STI testing and might be considered ‘low risk’ attendees. In such circumstances, traditional face-to-face consultations and the taking of an extensive medical history by a healthcare professional might not be necessary. However, if during the consultation process (face-to-face or electronic) the patient is deemed to be at high risk of STIs, is symptomatic or requires assessment for emergency contraception, postexposure prophylaxis or may have safeguarding needs, then the patient should be referred to a suitable healthcare worker for a more detailed assessment and management. There are many sexual health services which now offer an online consultation/’no-talk’ service by self-completed questionnaires and computer-assisted structured interviews (CASI).5 Studies have shown that in many cases, reporting by CASI was more reliable, with more patients divulging potentially risky sexual behaviour than when asked via face-to-face interviews.6 This method may also be more efficient, and has been shown to be acceptable to patients, although language and literacy will need to be taken into consideration. Evidence shows a CASI approach to be acceptable in a sexual health setting with similar consultation times and few patients declining to answer risk questions.7 Although CASI may yield additional disclosures in sensitive question areas, some evidence shows staff may not act on this information and that overall STI or HIV detection rates may not improve.8 Some areas have also seen the introduction of the ‘eSexual health clinic’, which is an online clinical and public health intervention. Patients with chlamydia are diagnosed and managed via an automated online clinical consultation, leading to antibiotic collection from a pharmacy. This could be an innovative model to address growing population sexual health needs. Although it has its merits, particularly for people who may find it uncomfortable to discuss personal issues in a face-to-face environment, it is not a suitable method for vulnerable groups or those where there may be communication difficulties. (2D)9, 10 To target the youth population which is at highest risk of STIs and HIV, public health interventions have increasingly turned towards the use of social media and Internet technology. Online resources which are available include online STI/HIV testing, online counselling, partner notification and education services. (2D)10 Where a face-to-face consultation is conducted, consideration should be given to the clinical setting. Ideally, this would be a suitable sound-proof room which provides an environment to discuss sensitive issues and develop a clinician–patient rapport to facilitate information exchange. During history taking, it is important to ask the following in female patients: For male patients, the following symptoms should be enquired about: In both male and female patients, ask about: Following on from the symptoms, it is important to ask about the patient's general health, sexual history and social history. Onward referral to appropriate services that can support chemsex users towards abstinence or risk reduction strategies should be considered. (2D) An assessment of blood-borne virus (BBV) risk will identify characteristics associated with high risk of HIV, hepatitis B and hepatitis C acquisition Increasingly sexual health clinics are providing an integrated STI and contraception service. The contraceptive and reproductive health history may therefore vary according to whether the service primarily has an STI testing and treatment focus or is providing an integrated service. A group which often faces healthcare disparities and barriers to care are the transgender and gender diverse populations. Healthcare providers need to be trained to use the appropriate terminology and pronouns. They also need to be mindful of heteronormative assumptions and take steps to ensure they are knowledgeable about transgender health to create a welcoming, inclusive and affirming clinical environment. Many providers assume that transgender patients do not need services such as pelvic examinations or contraception, or that treating transgender patients is too complex for their practice.19 These dynamics contribute to significant disparities in sexual and reproductive health for transgender people. Clinics should train providers and staff on transgender appropriate care, non-discrimination and inclusivity.20 Specific factors to consider in the trans-population It is rarely necessary to examine the patient if there are no symptoms. Studies have shown low rates of clinical findings in asymptomatic women attending a consultation for STI. Signs are found in less than 4% of cases, and many of these are of doubtful clinical significance such as asymptomatic bacterial vaginosis or candidiasis, genital warts and molluscum contagiosum. In view of this, a genital examination is not necessary in these cases. (2C)22-26 In asymptomatic men, first void urine samples and asymptomatic women self-taken vulvovaginal swabs for nucleic acid amplification testing (NAAT), provide sensitive and specific results for Chlamydia trachomatis and Neisseria gonorrhoeae, and avoid the need for intimate examination which may deter some patients from attending.27-29 In MSM, oropharyngeal and self-taken rectal swabs are a viable and acceptable option. (1B)30-33 However, patients presenting with symptoms suggestive of a possible STI should have a physical examination. Suitable facilities for examination should be available, with examination couches, appropriate lighting and equipment to take necessary samples. Examination should include the following: Examination of a patient who has been victim of sexual assault should occur after considering the need for forensic examination with an appropriate time frame for recovery of evidence. Not all clinics will need, or be able, to provide a forensic service, but a protocol for local referral must be available. Staff should follow local processes for the taking, storage and transportation of microbiological samples. When ordering investigations for STIs, the window periods need to be taken into consideration. Knowledge of local laboratory assays is required to determine window periods for infections and therefore guide advice about the need for repeat testing. All patients should be offered testing for Other infections should be tested for based on history, examination findings and the local availability of tests. Please refer to the IUSTI European guidelines available via this link https://iusti.orgregionsEuropeeuroguidelines.htm.34 The need for testing extra-genital sites in women should be considered according to the sexual history. Services may need to decide a local policy on screening asymptomatic women at pharyngeal and rectal sites pending further studies and data on cost-effectiveness. (2C) Clinics should be familiar with the assays used locally and sensitivities may vary for extra-genital sites, and not all are approved for extra-genital testing. This guideline will be kept under regular review by the editorial board of the European STI guidelines project, and an update initiated when the board feels that there is a need for it. At the latest, a new version will be produced five years after the publication of this one. See: https://www.iusti.org/regions/europe/pdf/2017/EditorialBoardSept2017.pdf Please refer to the link below for the list of the contributing organizations. https://www.iusti.org/regions/europe/pdf/2017/EditorialBoardSept2017.pdf The writing group would like to thank everyone who contributed comments and feedback during the consultation process. A literature search was performed using EMBASE, CINAHL, MEDLINE and PubMed from 2004 to 2017 for publications in English using the following terms/Medical Subject headings – “sexual history consultation”, “sexual history taking”, “medical history taking”, “medical history taking and sexually transmitted infections”, “sexually transmitted infections” OR “STI's”, “sexually transmitted infections AND” “sexual history taking”, “safeguarding”, “vulnerable patients”, “safeguarding” and “safeguarding AND vulnerable patients”, “chemsex”. The results of the searches were sifted by reading the titles and/or abstracts and potentially relevant papers obtained in full text. Relevant papers were then appraised. The search was limited to humans and the English language. The following guidelines were reviewed in detail – BASHH guidelines on sexual history taking and STI testing and the previous version of the European guideline for the organization of a consultation for sexually transmitted infections (2012). Priority was given to randomized controlled trial and systematic review evidence and, where possible, recommendations were made and graded on the basis of the best available evidence (see Appendix 2 for grading of evidence). In areas where evidence is lacking, conclusions were reached by informal consensus within the writing group. For details of the tables of evidence and grading of recommendations, please see https://www.iusti.org/regions/europe/pdf/2017/ProtocolForProduction2017.pdf Neither the authors or editors had any conflicts of interest for the content of this guideline, please see https://www.iusti.org/regions/europe/pdf/2017/ProtocolForProduction2017.pdf