Abstract
Summary
This study compares the testing rates of bacterial sexually transmitted infections (STIs) among HIV-positive men who have sex with men (MSM) attending two HIV clinics in Melbourne. Data on STI testing over a 12-month period were obtained for all HIV-positive MSM who attended the clinics between January and March 2006. Screening rates for bacterial STIs were significantly higher at a sexual health clinic (n = 254) compared with an infectious diseases clinic (n = 351), whether this was measured according to: at least one STI test being performed for chlamydia, gonorrhoea or syphilis (69% vs. 38%, P < 0.01); serological testing for syphilis alone (67% vs. 34%, P < 0.01); or ‘complete’ STI screening for pharyngeal gonorrhoea, urethral chlamydia, anal gonorrhoea, anal chlamydia and syphilis (41% vs. 6%, P < 0.01). Substantial differences in STI testing rates among HIV-positive MSM may exist between HIV clinical services depending on the measures in place that promote STI screening.
Introduction
Between 2000 and 2005, the annual number of notifications for HIV increased in Australia and Victoria after a long period of decline, with most diagnoses occurring among men who have sex with men (MSM).1,2 Bacterial sexually transmitted infections (STIs) enhance the transmission of HIV and targeted STI screening of HIV-infected people has been recommended as a key strategy for reducing HIV transmission.3–4
There are few studies, however, that compare the rates of STI testing among HIV-positive MSM attending different clinic settings. The aim of this audit was to compare the rates of testing for bacterial STIs and test positivity rates among MSM attending two HIV outpatient clinics in Melbourne.
Methods
This was a retrospective audit of medical records from two outpatient HIV clinics in Melbourne, one located within the Melbourne Sexual Health Centre (MSHC), the other at the Alfred Hospital Infectious Diseases Unit.
Patients were eligible for this audit, if they had attended either HIV clinic on at least one occasion between 1 January 2006 and 31 March 2006, and if they had also been attending that clinic for at least 12 months. The medical records of patients fulfilling these criteria were reviewed, together with data on testing for bacterial STIs.
At the sexual health clinic, an alert, consisting of an A4-size, pink-coloured proforma, was inserted into the medical notes of all new HIV patients, and at each subsequent consultation where STI screening was due. This acted as a reminder and also provided a dedicated section where standardized notes were recorded on: recent sexual history; whether screening was offered; the agreed frequency of future screening (ranging between three months and 12 months); if screening had already been conducted elsewhere; and if screening was declined, the reasons for this.
During the period audited, the infectious diseases clinic initially had a policy of testing all HIV-positive MSM for STIs attending during two designated periods each year: from February to March, and then, from November to December. From August 2005, the policy was changed so that STI screening was to be offered to patients at their initial presentation and then at six monthly intervals thereafter for those not screened in the interim by their primary care provider. Ethical approval for this audit at both sites was obtained from the Alfred Hospital Ethics Committee, Melbourne, Australia.
Results
During the audit period, 380 HIV-positive patients attended the MSHC HIV clinic. Of these, 254 were MSM who met the inclusion criteria. The mean age of these men was 47 years (range 25–81).
Over the same period, 592 HIV-positive patients attended the Alfred Hospital infectious diseases clinic. Of these, 351 were MSM who met the inclusion criteria. The mean age of these men was 47 years (range 25–75).
The proportions of HIV-infected MSM who were screened for bacterial STIs at the two clinics are compared in Table 1. Screening rates for bacterial STIs were significantly higher at the sexual health clinic compared with the infectious diseases clinic, whether this was measured according to: (a) at least one STI test being performed for chlamydia, gonorrhoea or syphilis (P < 0.01); (b) testing for both chlamydia and gonorrhoea concurrently (P < 0.01); (c) serological testing for syphilis alone (P < 0.01) or (d) ‘complete’ STI screening, that is, testing for pharyngeal gonorrhoea, urethral chlamydia, anal gonorrhoea, anal chlamydia and syphilis (P < 0.01). There was no significant change in the testing rates at the infectious diseases when complete screening rates among HIV-positive MSM attendees were compared before (2.8%) and after (3.2%) the change in screening policy at that clinic (P = 0.7).
Testing rates for STIs among HIV-positive MSM attending two HIV clinics in Melbourne (January–March 2006)
MSM = men who have sex with men; CI = confidence interval; STI = sexually transmitted infection
Tested in the preceding 12 months for at least one of the following: urethral or anal chlamydia, pharyngeal or anal gonorrhoea or syphilis
Tested for chlamydia from at least one site and gonorrhoea from at least one site
Specimens were obtained from the pharynx, urethra and anus and serological testing for syphilis was undertaken
The number of chlamydia and gonorrhoea infections according to anatomical site and the overall test positivity rates for these infections combining anatomical sites are shown in Table 2. The overall test positivity rate for chlamydia was significantly higher at the sexual health clinic. Although the test positivity rate for gonorrhoea was also higher at this service, this did not reach statistical significance.
Detection rates for chlamydia and gonorrhoea among HIV-positive MSM attending two HIV clinics in Melbourne (January–March 2006)
No. = number; MSM = men who have sex with men; CI = confidence interval
Chlamydia testing was by strand displacement amplification at Melbourne Sexual Health Centre (MSHC) and polymerase chain reaction (PCR) at the Infectious Diseases clinic
Site was not stated with one chlamydia infection
Gonorrhoea testing was by culture at MSHC, and by PCR or culture at the Infectious Diseases Clinic
Discussion
In this audit, there were major differences in the rates of testing for bacterial STIs among HIV-positive MSM attending different HIV clinics, which may reflect differences in approaches to STI screening. The incorporation of consistent and proactive STI screening into the routine care of HIV-positive MSM by a sexual health clinic achieved rates of ‘complete’ STI testing that were six times higher than that seen at an infectious diseases clinic.
A limitation of this audit is that information on the sexual history of MSM attending the infectious diseases clinic was not available. Therefore, we cannot be certain that these men were as sexually active or as much in need of STI screening as men seen at the sexual health clinic.
If the lower rates of STI testing at the infectious diseases clinic did, in fact, reflect lower screening rates of sexually active HIV-infected MSM, this probably reflects differences in clinic policies and procedures. At the MSHC, where the provision of STI screening is a core function of the service as a whole, and where a high proportion of the HIV providers are sexual health physicians, a consistent and proactive policy for STI testing of HIV positive sexually active patients was in place. Although the screening protocol at the infectious diseases clinic changed during the period studied in an effort to increase STI testing, testing rates did not increase significantly and remained substantially lower than those seen at the sexual health clinic.
Previous audits that have examined STI screening rates among HIV-positive MSM in Australia have not compared different clinical sites, while an audit on STI screening among HIV-positive patients at London clinics did not focus on MSM specifically.5–7
Although STI testing of sexually active HIV-positive MSM has been advocated as a key component of HIV control, the necessary supports and structures need to be in place for it to be successful. With the high rates of bacterial STIs seen among the HIV-infected MSM in this and other studies, efforts to ensure the universal implementation of routine STI testing of this group appear justified.
Footnotes
Acknowledgements
MC is supported by NHMRC Fellowship 400399.