Abstract
Guidelines for the sexual health care of our HIV patients and provision of post-exposure prophylaxis following sexual exposure have been produced by both British Association of Sexual Health & HIV and British HIV Association (BHIVA). In the light of recent criminal prosecutions, BHIVA produced guidance for HIV clinical teams regarding discussions with patients about HIV transmission and reducing the risk to sexual partners. This audit examined the advice given to HIV patients with regard to safer sexual practices, sexually transmitted infection screening and partner notification and found that, on the whole, the standards set by national guidelines were adhered to, although areas for improvement were identified. We hope that the introduction of proformas with specific prompts for these subjects for HIV clinic visits will improve clinical standards in this area.
Keywords
INTRODUCTION
The sustained increase in newly acquired cases of HIV infection in the UK, 1 together with notable levels of sexually transmitted infections (STIs) among HIV-positive individuals, 2 makes addressing the sexual health needs of our HIV patients crucial. The British Association of Sexual Health & HIV (BASHH) and the British HIV Association (BHIVA) together with BASHH and the Faculty for Sexual and Reproductive Healthcare have produced guidelines that set the standard for sexual health care within HIV services. 3,4 In addition, the recent prosecutions of HIV-positive individuals for the ‘reckless transmission’ of HIV 5 have made the discussion of safer sexual practices and HIV disclosure pertinent. BHIVA has produced a briefing paper issuing advice for the HIV clinical team, 6 and an explanation of the routes of HIV transmission and the ways of protecting others from infection is considered an important part of HIV clinical care. Guidelines have also been produced by BASHH for post-exposure prophylaxis following sexual exposure (PEPSE) to HIV, 7 and in a letter in April 2006 the Chief Medical Officer for England and Wales specifically requested that all primary care trusts make this available to those who require it. 8
The aims and objectives of this audit are to assess whether HIV-positive patients are counselled appropriately with regard to disclosure to sexual partners and safer sexual practices (including condom use and PEPSE), and also whether sexual histories are taken and screening for STIs is offered regularly, in accordance with the national guidelines. 3,4
METHODS
A retrospective case-note audit of 100 HIV patients attending the Manchester Centre for Sexual Health in June 2008 was performed. The patients were divided into two groups (50 patients in each). The first group (A) comprised newly diagnosed patients and the notes for the first six months after diagnosis were reviewed to see whether the following standards had been met: full sexual history and STI screen performed, methods of preventing HIV transmission discussed, disclosure to current partner(s) and traceable contacts informed and tested. The second group (B) comprised patients diagnosed at least 18 months previously attending HIV clinics from 2 June to 13 June 2008; the audit examined documentation for the preceding 12 months with regard to the following standards: repeat sexual history taken at least every six months, STI screening offered at least every 12 months, and ongoing discussion regarding safer sexual practices and PEPSE.
RESULTS
Demographics
Of the audit sample (n = 100), 72 were men and 28 women; 55 homosexual, 38 heterosexual, two bisexual and five cases were not documented. The majority (88) were aged between 20 and 50 years; and 59 were Caucasian, 30 black African and 11 from other ethnic backgrounds.
Compliance with Audit Standards
These are given in Table 1 (Group A) and Table 2 (Group B). This was the first audit performed by the person collecting the data and some errors became apparent after data collation: firstly the forms were incomplete in a few instances (as shown in the tables), and secondly in extracting data from the notes retrospectively it was difficult to assess whether STI screening was specifically discussed as a method of reducing HIV transmission (as persons with concurrent STIs have a higher risk of transmitting HIV to their partners). Because regular STI screening was frequently recorded, compliance with this audit standard is probably artificially low.
Audit outcomes for group A; patients within six months of HIV diagnosis
*See explanation in the Results section
STI = sexually transmitted infection; PEPSE = post-exposure prophylaxis following sexual exposure
Audit outcomes for group B; patients over 18 months from HIV diagnosis
*See explanation in the Results section
STI = sexually transmitted infection; PEPSE = post-exposure prophylaxis following sexual exposure
DISCUSSION
The results indicate that for newly diagnosed patients almost all have a full sexual history taken and STI screen offered and performed. A discussion regarding disclosure was documented in all case-notes with disclosure to the current partner documented where applicable in most cases (84%), and traceable contacts informed in 86% and tested in 73%. The clinical team was also fairly good at documenting advice regarding condom use and PEPSE with patients, although an obvious area of improvement is documentation of advice regarding PEPSE, which was recorded in 73%. In the group of follow-up patients, although 84% had STI screening performed every 12 months, only 62% had repeat sexual histories documented. With regard to prevention of onward HIV transmission, discussions regarding condom use and PEPSE were documented in 74% and 64% of cases, clearly less often than in newly diagnosed patients.
Clinical practice may be improved in this area by the implementation of proformas for both new patients and follow-up visits; these include prompts to take sexual histories, discuss disclosure, condom use and PEPSE, document their partner's HIV status, and whether they are aware of the patient's status, and offer STI screening. An information sheet for patients with regard to PEPSE has also been produced. The use of these proformas should also make data collection easier for future audit. As disclosure is an ongoing issue for individuals living with HIV, a future audit should evaluate discussions between the clinical teams and patients after the initial diagnosis period.