Improved sexual history taking in the 2012 BASHH asymptomatic screening re-audit

Abstract

Effective asymptomatic screening for sexually transmitted infections is an important public health service because a significant proportion of sexually transmitted infections do not present with symptoms. In 2009, the National Audit Group of the British Association of Sexual Health and HIV (BASHH) audited the management of asymptomatic patients and recommended increased documentation about oral and anal sex, regional strategies for nucleic acid amplification test (NAAT) use for gonorrhoea, improved screening for hepatitis B in men who have sex with men and an increase in screening for HIV. The 2012 audit used web-based forms to collect submissions from 180 consultant-led centres (65% response rate) that included episodes of care from 6669 asymptomatic patients. An improvement was demonstrated for all the areas measured during the 2009 audit. A doubling of gonorrhoea testing using NAATs was seen and yet 10% of asymptomatic patients continued to have microscopy despite these tests not being recommended by BASHH guidelines. This audit recommends universal adoption of gonorrhoea NAATs across the United Kingdom.

Keywords

Sexually transmitted infection Gonorrhoea (Neisseria gonorrhoeae)Chlamydia (Chlamydia trachomatis)Europe diagnosis screening nucleic acid amplification tests audit

Introduction

Effective asymptomatic screening for sexually transmitted infections (STIs) is an important public health service because a significant proportion of STIs do not present with symptoms. Detecting infections in asymptomatic patients provides an opportunity to identify, test and treat people in sexual networks. The National Audit Group of the British Association of Sexual Health and HIV (BASHH) re-audited the management of asymptomatic patients presenting for sexual health screens in 2012 following the baseline audit in 2009.¹ Both audits were performed against the 2006 BASHH guidelines on consultations requiring a sexual history. The baseline audit suggested four areas for practice improvement, which were given below:

Increased documentation of the discussion about oral and anal sex to identify which anatomical sites should be sampled for infection.

Regional strategies should be considered to balance nucleic acid amplification testing for gonorrhoea with culture testing to monitor antibiotic sensitivity.

Increased screening for hepatitis B in men who have sex with men (MSM) is needed in some regions.

Increased screening for HIV is needed in some clinics.

The re-audit was designed and performance data were analysed with these recommendations in mind, to determine whether the quality of services had improved over three years.

Methods

All United Kingdom (UK) Level III (i.e. consultant-led) services were invited to submit data on 40 consecutive patients attending during the audit interval (1 October to 31 December 2011). Data were collected between 7 January and 15 April 2012. The inclusion criteria were cases reporting no symptoms on presentation (either on a form or on direct questioning from a health care professional) and were seen during a new or rebook episode. The re-audit comprised a reduced number of questions targeting those areas highlighted as being of concern in the previous audit. All data were collected using a web form² and collated into a National (comprising 17 branches that included Wales, Scotland and Northern Ireland) aggregate and regional (composed of clinics) aggregates in pivot tables.

Results

During the audit period, 180 of 278 (65%) clinics participated in the audit. A total of 6669 asymptomatic patients’ case notes were audited, and the gender and sexuality of these patients is shown in Table 1. The percentage of patients who had sexual histories or recommended tests taken is shown in Table 2, with 2009 audit data for comparison. Finally, the use of microscopy in these asymptomatic patients is shown in Table 3. Detailed data, aggregated by region, are available on the BASHH website: http://bit.ly/17Ae5qK.

Table 1.

Gender and sexual orientation of patients.

Gender	Heterosexual, number (%, regional range)	Homosexual, number (%, regional range)	Bisexual, number (%, regional range)	Total number
Male	3020 (90%, 83–95%)	266 (8%, 4–15%)	62 (2%, 0–3%)	3348
Female	3291 (99%, 98–100%)	10 (0.3%, 0–1%)	20 (0.6%, 0–2%)	3321
Total	6311	276	82	6669

Table 2.

Percentage, and percentage change, in sexual history and testing events in the 2009 and 2012 BASHH asymptomatic screening audits.

Auditable outcome	2009 (%)	2012 (%)	Change (% improvement)
Oral sex discussion
MSM	81	92	+11
Women	45	52	+7
Anal sex discussion
MSM	88	91	+3
Women	39	50	+11
Gonorrhoea NAATs provided
Heterosexual men (Urine NAAT)	36	67	+31
Rectal NAAT MSM	15	50	+35
NAAT testing women	23	58	+35
Screening for hepatitis B provided (of those eligible)
Heterosexual men	24	77	+53
MSM	82	92	+10
Women	23	68	+45
HIV testing accepted
Heterosexual men	83	88	+5
MSM	95	97	+2
Women	81	85	+4

BASHH: British Association of Sexual Health and HIV; MSM: men who have sex with men; NAAT: nucleic acid amplification test.

Table 3.

Use of microscopy when testing asymptomatic patients.

Test	Performed, number (%, regional range)	Declined, number (%, regional range)	Not performed, number (%, regional range)	No record in notes, number (%, regional range)
Men
Urethral microscopy	341 (10%, 0–23%)	14 (0.4%, 0–2%)	2082 (62%, 33–82%)	911 (27%, 4–62%)
Women
Cervical microscopy	303 (9%, 2–15%)	7 (0.2%, 0–1%)	2108 (64%, 37–93%)	903 (27%, 1–54%)
Urethral microscopy	130 (4%, 0–13%)	3 (0.1%, 0–1%)	2182 (66%, 44–99%)	1006 (30%, 1–57%)

Discussion

An improvement in history taking and testing for all groups between the two audits has been clearly demonstrated in Table 2. The change in history taken regarding oral and anal sex in MSM and the testing of these sites is an important opportunity to detect infections.^3,4 Even though rectal nucleic acid amplification testing increased threefold between the two audit periods, it still was only used in half of MSM. It has been demonstrated that the rectum⁵ and the pharynx^6,7 are important infection reservoirs in MSM, and it is possible that the lack of testing and treatment of infections at these sites in women, when directed by sexual history, has a role in sustaining the epidemics of chlamydia and gonorrhoeal infection.

The increasing use of nucleic acid amplification tests (NAATs) is a welcome development for two reasons: first, because NAATs are more sensitive diagnostic tests and second, their adoption seems to be associated with a decrease in the use of tests not currently recommended by the Clinical Effectiveness Group of BASHH. For instance, use of a combined urine NAAT for chlamydia and gonorrhoea can obviate the need for a urethral swab in asymptomatic men. However, Table 3 shows that nearly 10% (644/6669) of patients were tested by microscopy (and, by extension, gonococcal culture) because a NAAT test was not available. Not utilising NAATs in these clinics resulted in the use of tests for gonorrhoea with lower sensitivity as well as the need to undress and perform an invasive test in asymptomatic patients (see Table 3). Presentation of these data at the joint BASHH/ASTDA (American Sexually Transmitted Disease Association) Spring conference in Brighton in June 2012 led to discussion about the inequity in access to NAATs and concern was expressed that this may present a barrier to testing. Some of the clinics performing invasive tests may also be screening for non-gonococcal urethritis though this was not specifically asked within this audit.

This audit did not have submissions from all Level III genitourinary medicine clinics in the UK and it may be that the data presented are not fully representative of current practice. The type of the reporting clinic as well as the size of the local population were not captured in this audit; however, the larger clinics from all branches are represented in the audit and the smaller clinics tend to follow the practice of their larger hub centre. In this fairly large sample, there has been an improvement in the quality of history taking and testing. The biggest single finding is the stepwise increase in the use of NAATs for gonorrhoea detection.

Recommendations

To continue to improve on history taking and testing performance demonstrated in this audit.

Universal adoption of gonorrhoea NAATs across the United Kingdom.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare no conflict of interest.

References

BASHH. National Guidelines – consultations requiring sexual history-taking, http://www.bashh.org/documents/84/84.pdf (2006, accessed 31 August 2013).

http://www.dataillusion.com (2013, accessed 28 April 2013).

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