Increasing screening frequency in men who have sex with men: impact of guidance on risk profiling on workload and earlier diagnosis of sexually transmitted infection and HIV

Abstract

Summary

Increasing screening frequency in men who have sex with men (MSM) engaging in high-risk behaviours can reduce prevalence of sexually transmitted infections (STIs). This evaluation investigated the impact of applying stricter screening guidelines for MSM on service workload and earlier STI diagnoses. A validated risk assessment tool (RAT) was distributed to MSM attending a level 3 sexual health service over three months. Australian screening guidelines were applied to the data to identify MSM requiring more frequent screening and data projected to the larger MSM population. The RAT identified a 2–5-fold increase in the number of STI and HIV screenings required based on six- and three-monthly screening intervals, respectively, in the MSM cohort. When screening intervals are reduced from three-monthly to six-monthly there is a potential loss of 66.7% of earlier HIV diagnoses. The use of RATs will increase workload in sexual health services, but potentially diagnose a large proportion of disease earlier.

Keywords

HIV AIDS sexually transmitted infection screening diagnosis high-risk behaviour homosexual MSM sexual behaviour

INTRODUCTION

Within the UK, both HIV and sexually transmitted infection (STI) diagnoses are increasing in men who have sex with men (MSM).¹ Additionally, sexual risk-taking behaviour in MSM is also rising, with an increasing proportion of MSM reporting an increased number of sexual partners and an increase in unprotected anal intercourse.² These factors make improving the sexual health of MSM a priority.

Modelling studies have indicated that increased frequency of HIV and STI screening in MSM could significantly reduce onward transmission of HIV, and mitigate syphilis epidemics. Specifically targeting MSM practising high-risk sexual behaviours makes this strategy more efficient.^3,4

Sexual risk-taking behaviours have been defined by the Australian STIs in Gay Men Action Group (STIGMA) whose 2010 guidelines were developed using evidence from multiple sources including emerging epidemiological patterns in the UK, with the risk assessment tool (RAT) endorsed by multiple Australian medical professional bodies.⁵ The guidelines recommend 3–6 monthly testing for MSM who within the last year have engaged in unprotected anal sex, group-sex, or used recreational drugs during sex, or who have 10 or more sexual partners in the past six months. STIGMA guidelines advise that MSM should be tested for chlamydia (by nucleic acid amplification test [NAAT]) and gonorrhoea (by NAAT or culture) on first void urine, pharyngeal and anal swabs, and should have serology for HIV, syphilis, hepatitis A and B, and hepatitis C if HIV positive or an injecting drug user. The Australian STIGMA guidelines are very similar to the USA Centers for Disease Control and Prevention (CDC) guidelines advising 3–6 monthly testing for MSM practising high-risk sexual behaviours.⁶

Current UK guidelines for screening MSM are vague with National Institute for Health and Clinical Excellence (NICE) guidance advising annual screening for MSM and increased screening for those with sexual risk-taking behaviours.⁷ It does not however clarify these behaviours or the increased screening frequency.

In response to the changing epidemiology in the UK, a number of organizations including the Terrence Higgins Trust are developing UK screening guidelines for MSM. However the service impact of such strategies has not been modelled and there is limited evidence to show whether this increased testing would be effective in diagnosing HIV and STIs earlier.

AIMS

The aims of this service evaluation were to investigate the impact of applying stricter international screening guidelines for MSM participating in high-risk sexual behaviours on service workload in a UK level 3 sexual health service, and whether these stricter screening guidelines could potentially lead to the earlier diagnosis of HIV and STIs, prior to implementing these changes within our clinic.

METHODS

MSM who attended a large provincial level 3 sexual health service over a three-month period between October 2011 and January 2012 were invited to complete a questionnaire, which consisted of two discreet RATs. The first RAT was based on the Australian 2010 STIs in Gay Men Action Group (STIGMA) guidelines, and explored having more than 10 partners in the past six months, episodes of unprotected anal sex, participation in group sex or use of recreational drugs during sex in the past 12 months.⁵

The second RAT (called the non-STIGMA RAT) was developed in-house and explored the sexual risk-taking behaviours as reviewed by the STIGMA RAT in addition to other risk-taking behaviours in the past 12 months identified by literature review. These additional risk-taking behaviours were: attending sex-on-premises venues, using recreational drugs, seeking partners via the Internet or Smartphone applications, and having sex in a public place.^8–11 The non-STIGMA RAT was piloted on 20 MSM for internal validation. For the purposes of evaluation of the non-STIGMA RAT only those MSM engaging in the additional sexual risk-taking behaviours not explored by the STIGMA RAT were analysed, in order to assess the additional impact on workload adding additional questions to the STIGMA RAT would generate.

The questionnaire also explored the frequency of HIV and STI tests in the prior 12 months, HIV status, and all recent new STI or HIV diagnoses.

Clinic testing protocol for MSM was for chlamydia and gonorrhoea NAATs from all sites at risk (first void urine, pharyngeal and proctoscopically-taken rectal swabs) with duplicate gonorrhoea cultures for symptomatic patients, and serology for HIV, syphilis, hepatitis B and hepatitis C at every attendance where there had been a new risk.

Australian STIGMA 2010 screening guidelines for MSM were applied to the data, and the proportion of MSM that would need to be screened more frequently (as identified by their sexual behaviour and prior screening frequencies over the prior 12 months) was identified. This was used to indicate the impact of increased screening on workload. Since the guidelines indicate that those engaging in high-risk behaviours should ideally be screened at three monthly intervals and, if this is not possible, at least six-monthly, we separately assessed the number of extra screenings generated for both three- and six-monthly screening intervals (at all times the number required was compared with the actual number of screenings the participants had undergone). Any respondents admitting to risk factors explored in the non-STIGMA RAT were also assigned to the more frequent 3–6 monthly testing group (equating these additional risks equally to the high-risk behaviours defined by STIGMA).

Those MSM who were identifiable questionnaire respondents with a new HIV or STI diagnosis were analysed to identify whether they would have qualified for additional screening based on STIGMA or non-STIGMA risk-taking behaviours.

This service evaluation was approved by the NHS Trust in which it was conducted.

Analysis

Analysis was performed using Excel V12.2.6. Information regarding risk behaviours, prior screening frequencies, HIV status, and all recent new HIV and STI diagnoses were collected from the questionnaires. Information on patient demographics, and HIV and STI diagnoses made and screening performed at our clinic were collected from the electronic patient record. For MSM attending within the evaluation period who did not answer an identifiable questionnaire, information on demographics, and HIV and STI diagnoses made and screening performed at our clinic were collected using the electronic patient record. Differences in the number of STI and HIV diagnoses between identifiable questionnaire respondents and other MSM clinic attendees were examined using the χ² test. Differences in mean age were analysed using the paired t-test.

Results

During the three-month period 126 of 357 MSM attending the sexual health service completed the validated questionnaire. Of these, 89 questionnaire respondents were identifiable (i.e. their questionnaire could be linked to their electronic patient record using their unique clinic number, allowing information in their patient record to be used), and further analysed. Thirty-seven questionnaire respondents were not identifiable because a clinic number had not been placed on the questionnaire by clinic staff before they completed it.

The 357 MSM attending with the three-month evaluation period represent 45.0% of the entire MSM cohort who attended during the 12-month period of 2011 (many MSM attended multiple times but each MSM in the cohort represents an individual rather than an attendance).

Baseline demographic data for the sample group of identifiable questionnaire respondents and other MSM attendees are shown in Table 1. The sample group was assumed to be representative of the entire MSM cohort attending during the evaluation period as most baseline demographics were comparable (with the exception of being single), and risk-taking behaviour extrapolated to that entire cohort.

Table 1

Baseline demographic data

	Identifiable questionnaire respondents(n = 89)	Other MSM attendees (n = 268)	P value
White ethnicity	74 (83.2%)	228 (85.1%)	0.73
Mean age (years)	35.0	38.6	0.76
‘Single’ relationship status (rather than in a committed relationship with a regular sexual partner)	42 (47.2%)	160 (59.7%)	0.04
New STI diagnosis	18	75	0.18
New HIV diagnoses	3	12	0.62

STI = sexually transmitted infection; MSM = men who have sex with men; STIGMA = STIs in Gay Men Action Group

Prevalence of sexual risk-taking behaviours

In total, 59.6% of identifiable questionnaire respondents were engaging in sexual risk-taking behaviours identified by the questionnaire (see Figure 1).

Figure 1

Sexual risk-taking behaviours identified by the questionnaire (STIGMA risk behaviours shown in black and additional non-STIGMA risk factors shown in grey)

Change in workload generated by STI and HIV screening at 3- and 6-monthly intervals

Australian 2010 STIGMA screening guidelines were applied to the data identifying MSM engaging in STIGMA sexual risk-taking behaviours and therefore requiring additional screening. The number of additional screens required is dependent on their prior screening frequency in the past 12 months, i.e. their actual screening frequency subtracted from their required screening frequency to obtain the additional number of screens required.

Table 2 shows the increase in STI and HIV screening required when applying three- and six-monthly screening intervals to MSM engaging in high-risk sexual behaviours identified by STIGMA guidelines. When applying three-monthly screening intervals to MSM engaging in high-risk STIGMA behaviours, of the 357 MSM attending during the evaluation period, 220 (61.6%) were identified as requiring additional STI screening in the previous 12 months, with an additional 563 STI screens required in total (a 134.0% increase). A total of 167 MSM (46.8%) were identified as requiring additional HIV screening in the previous 12 months, with an additional 439 HIV screens required in total (a 121.7% increase).

Table 2

Increase in workload generated by applying STIGMA screening guidelines for MSM attending a level 3 genitourinary medicine clinic

		Increase in workload generated when screening at 3-monthly intervals for MSM engaging in STIGMA or additional risk behaviours					Increase in workload generated when screening at 6-monthly intervals for MSM engaging in STIGMA or additional risk behaviours
		1 extra screen required	2 extrascreensrequired	3 extrascreensrequired	4 extrascreensrequired	Screensgeneratedoverall	1 extrascreenrequired	2 extrascreensrequired	Screensgeneratedoverall
Evaluation period (Applying STIGMA guidelines) (357 MSM)	STI	6.7% (28 extra screens)	35.2% (148 extra screens)	60.7% (255 extra screens)	31.4% (132 extra screens)	134.0% increase (563 extra screens)	21.7% (91 extra screens)	16.2% (68 extra screens)	37.9% increase (159 extra screens)
Evaluation period (Applying STIGMA guidelines) (357 MSM)	HIV	3.9% (14 extra screens)	29.9% (108 extra screens)	65.7% (237 extra screens)	22.2% (80 extra screens)	121.7% increase (439 extra screens)	25.8% (93 extra screens)	11.1% (40 extra screens)	36.9% increase (133 extra screens)
*Evaluation period with additional non-STIGMA risk factors^†	STI	1.9% (8 extra screens)	5.2% (22 extra screens)	14.3% (60 extra screens)	5.7% (24 extra screens)	27.1% increase (114 extra screens)	4.8% (20 extra screens)	1.4% (6 extra screens)	6.2% increase (26 extra screens)
	HIV	0.8% (3 extra screens)	7.8% (28 extra screens)	20.8% (75 extra screens)	0.0% (0 extra screens)	29.4% increase (106 extra screens)	6.9% (25 extra screens)	0.0% (0 extra screens)	6.9% increase (25 extra screens)

STIGMA = STIs in Gay Men Action Group; MSM = men who have sex with men

*Additional non-stigma risk factors = attending sex-on-premises venues, using recreational drugs, seeking partners via the Internet or Smartphone applications, having sex in a public place

^†The number of screens generated is in addition to those generated by applying STIGMA guidelines

When the screening interval was reduced to six-monthly, 125 MSM (35.0%) were identified as requiring additional STI screening in the previous 12 months, with an additional 159 STI screens required in total (a 37.9% increase). In total, 113 (31.7%) MSM required additional HIV screening in the previous 12 months, with an additional 133 HIV screens required in total (a 36.9% increase).

When numbers of MSM engaging in non-STIGMA sexual risk-taking behaviours (who had not previously been identified by the STIGMA RAT) were evaluated, and those risk behaviours considered equal to those identified by STIGMA (i.e. requiring additional screening at 3–6-monthly intervals), an increased number of MSM required additional screening. With a three-monthly screening interval, an additional 45 MSM (12.6%) would require additional STI screening in the previous 12 months, resulting in an additional 114 STI screens in total (a 27.1% increase). A further 42 MSM (11.8%) were identified as requiring additional HIV screening in the previous 12 months, resulting in an additional 106 additional HIV screens in total (a 29.4% increase).

When the screening interval was reduced to six-monthly, 23 MSM (6.4%) were identified as requiring additional STI screening, resulting in an additional 26 STI screens in total (a 6.2% increase). Twenty-five MSM (7.0%) were identified as requiring additional HIV screening, resulting in an additional 25 HIV screens in total (a 6.9% increase).

By combining the two RATS, there was a required increase of 44.1–161.1% in STI screens and 43.8–151.1% in HIV screens (for 6 or 3-monthly screening respectively).

STI and HIV diagnoses

During the three-month evaluation period 15 new HIV diagnoses and 93 STI diagnoses were made among all MSM attending the service. Of the 15 new HIV and 93 new STI diagnoses, 10 (66.7%) HIV and 59 (63.4%) STI diagnoses were in MSM who would require additional three-monthly screening as defined by STIGMA risk behaviours. In addition, three (20.0%) HIV and 21 (22.6%) STI diagnoses were in MSM who would require additional three-monthly screening based on reporting of additional non-STIGMA risk factors. By combining RATs there was therefore a potential possibility for up to 86.7% of HIV and 86.0% of STI cases to have been diagnosed earlier.

The assumption of possibility of earlier diagnosis was based on the individual's prior screening and risk profile. Lowering the screening frequency from three-monthly to six-monthly intervals reduced the possibility for earlier diagnoses: 3 (20.0%) HIV and 17 (18.3%) STI diagnoses potentially would have been diagnosed earlier based on reporting of STIGMA risk behaviours, and 0 (0.0%) HIV and 4 (4.3%) STI diagnoses based on reporting of additional non-STIGMA risk behaviours. By combining RATs there was a potential possibility for 20.0% and 22.6% of HIV and STI cases, respectively, to have been diagnosed earlier.

DISCUSSION

This evaluation demonstrates the significant number of additional STI and HIV screens required when applying strict screening guidelines to a MSM population attending a UK level 3 sexual health service. This workload generated is highly dependent on the RAT used and whether the decision to test three-monthly over six-monthly is taken when finding high-risk behaviours.

Use of the additional non-STIGMA RAT questions to identify MSM participating in high-risk behaviours not identified by the STIGMA RAT, resulted in a significant increase in potential earlier diagnosis of HIV and STIs (20.0% and 22.6% increase, respectively, with 3-monthly screening) and an increase in additional HIV and STI screening required across the MSM cohort (29.4% and 27.1% increase, respectively, with 3-monthly screening). This may indicate that using the STIGMA RAT alone is insufficient to identify all MSM who would benefit from more frequent screening.

However, potential gains from three-monthly screening (i.e. earlier diagnosis of HIV and STIs) were more marked in those MSM with STIGMA risk-taking behaviours (66.8% and 63.4%, respectively) in comparison with those with additional non-STIGMA risk-taking behaviours (20.0% and 22.6%, respectively). This may suggest that where resources are limited and not all men with high-risk behaviours can be screened more frequently, it may be better to concentrate on those with STIGMA risk-taking behaviours.

Opting to use screening intervals that may be more manageable for service workload (i.e. screening at 6-monthly intervals rather than 3-monthly) reduces the effectiveness of frequent screening by resulting in a potential loss of 66.7% and 63.4% of earlier HIV and STI diagnoses, respectively.

There are some limitations to this evaluation, including the relatively small sample size. The proportions of MSM engaging in high-risk sexual behaviours identified during the three-month evaluation period may not be typical of the larger population (the lower proportion of single MSM in the identifiable questionnaire respondents for example may well underestimate impact on workload), and patients may choose not to attend for more regular screening. However, numbers of MSM engaging in unprotected anal sex within the previous 12 months (52.8%) was broadly similar to national rates identified by NATSAL (59.8%)² and so the sample may be roughly representative of national MSM cohorts.

Currently a number of screening guidelines based on risk profiling for UK MSM are in development which will identify some MSM as benefiting from more frequent screening. It is essential to assess the impact on clinic work load such guidance would generate. A cost analysis was not included in this evaluation; however, other studies suggest that high rates of re-screening are cost-effective and achievable.¹² A recent study at a London sexual health clinic recalling MSM diagnosed with a bacterial STI after three months showed that high rates of re-screening were achievable and identified a number of important STIs and seroconverting HIV cases.¹²

This evaluation demonstrates that increased frequency of screening for MSM practicing high-risk sexual behaviours increases potential clinic workload. The workload generated will be highly variable depending on the RAT used to identify MSM at need of increased screening, and this variation in workload generated by different RAT designs should be of concern. However, the potential for associated earlier HIV diagnosis has the important advantage of reducing the undiagnosed population of people living with HIV. “The Halve It” campaign focuses on the benefits of increasing HIV diagnoses including reducing morbidity and mortality in undiagnosed people living with HIV and reducing onwards transmission.¹³

This evaluation demonstrates the value of increased screening frequency in MSM practicing high-risk sexual behaviours and therefore efforts to accommodate this additional workload need to be made. Clinics may need to consider methods to increase testing capacity such as the role of patient-taken swabs and point of care tests for HIV, in addition to methods aimed at increasing STI screening and detection in MSM. Effective methods include the use of a computer alert on an electronic medical record, the introduction of clinic guidelines on STI screening, text messaging reminders for repeat STI screening, and regular serological testing for syphilis during routine HIV care.^14,15 UK screening guidance should be urgently reviewed.

Footnotes

Acknowledgements

Declarations: None.

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