STI & HIV screening in Primary Care. Dr Paddy Horner Consultant Senior Lecturer University of Bristol Annette Billing Public Health, Bristol Council

Transcription

1 STI & HIV screening in Primary Care Dr Paddy Horner Consultant Senior Lecturer University of Bristol Annette Billing Public Health, Bristol Council

2 Outline Why Screen Advances in diagnostics how can we afford these tests? Chlamydia Geo-mapping Risk behaviour Unity Sexual Health Services Targeted digital health promotion ICE diagnostic and screening algorithms HIV Screening (> 2 in 1000) HIV associated disease

3 Why screen for STIs and HIV? To treat and eradicate sexually transmissible infections in index and contact(s) Reduce/prevent morbidity Index case Partners Confirmation index is free from infection Limited research on this Wider public health agenda on healthy relationships

4 Why screen for STIs and HIV? Avoid harm Stigma Anxiety and STI symptoms Is it cost effective?

5 Advances in STI diagnostics Rapid expansion in on-line STI testing Outstripping NHS expert advice Increasing promotion of new and accurate tests to NHS How do we afford these? Better use of existing tests Targeted introduction of new tests

6 Mycoplasma genitalium 2-3% young people 7% young people attending GUM Associated new sexual partner Associated NGU, cervicitis (PCB) and PID (mild) 5-10% co-infection with chlamydia Increases HIV transmission NAAT testing available Macrolide antimicrobial resistance 20-30% in some centres Azithromycin 1 gram probably causal Extended 3-5 day (2-3g) regimen preferred Doxycycline 100mgs bd 7 days 50% effective No resistance Taylor-Robinson Geniturin Horner Med 1995 et al Curr Opin inf Dis 2014; 27:

7 Trichomonas Vaginalis (TV) Women: Is it clinically important? Vaginal discharge 60-80% asymptomatic Associated New sexual partner Older age, BME, social deprivation Premature labour & Increased susceptibility to HIV Men NGU Majority asymptomatic On-going transmission

8 STI Positivity Rate % S-GUM A-GUM S-GP A-GP % N = TV CT NG! TV>CT

9 Black Caribbean Ethnicity - Bristol Montpelier HC 3.9% TV+ Easton FP 3.7% TV+ Lennard Surgery 5.8% TV+? Census 2011 Hartcliffe HC 3.1% TV+

10 High TV rates: link to deprivation? Deprivation Index (IMD) Deprivation Index (IMD) by practice fingertips.phe.org.uk

11 Chlamydia Common 4-9% young people (under 25) attending health care setting 2-4% sexually active population < 25 yrs Prevalence decreases after age 25 yrs Associated new sexual partner, social deprivation ¾ Testing Primary care > 25yrs, positivity 1-2% Nucleic acid amplification tests Revolutionised management Less uncertainty about natural history

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13 National Chlamydia Screening Programme (NCSP) A national prevention and control programme for genital chlamydial infection across England All 15-24yr olds should be screened for Chlamydia every year Opportunisitc 30% uptake Bristol

14 Chlamydia trachomatis Symptoms >50% no symptoms Signs Men Urethral discharge Dysuria Urethral itch or discomfort Rectal discharge Rectal bleeding Female Vaginal discharge Dysuria Pelvic pain PCB/ IMB Rectal discharge Rectal bleeding 70% no symptoms

15 Chlamydia PID 20% (35% 16-24yr old) Infertility Tubal factor accounts for 20-30% infertility 30% Male factor Conflicting evidence Ectopic pregnancy 5% Neonatal conjunctivitis + pneumonia Sexually acquired reactive arthritis Price M et al HTA report 2016 DOI: /hta20220 Gottlieb S JID 2010:201 S2:190

16 Natural history of chlamydia Every 1000 CT infections in women aged years gives rise to: 171 episodes of PID 73 episodes of salpingitis 5.1 women with TFI at age 44 years. 2.0 ectopic pregnancies Price M et al HTA report 2016 DOI: /hta20220

17 Number needed to test: PID prevention 1% prevalence need to test 1000 women to prevent 1 PID Cost test PID treatment costs

18 Age + STI Positivity Rate % S-GUM A-GUM S-GP A-GP % N 7.8 = CT <25 >25

19 CT positivity <25yrs 7% South West; 3.5% Primary care

20 CT testing BNSSG Women (70%) 35% NCSP ~ 7% positive 14% GP <25yrs ~ 4% positive 35% GP > 25yrs ~ <2% positive (50% asymptomatic) Are we testing the right people? Should we be targeting based on risk?

21 Chlamydia testing: can we do better? Develop geo-maps based on lower super output area (LSOA) PHE fingertips

22 Chlamydia detection rate

23 Chlamydia testing: can we do better? Develop geo-maps based on lower super output area (LSOA) PHE fingertips Greater detail Anonymised PHE microbiology and GUM LSOA Association with deprivation index Develop these for gonorrhoea, syphilis and HIV

24 PHE microbiology geo-maps Figure provides an example geo-map based on incidence per 100,000 of chlamydia and gonorrhoea at a ward level using data from Bristol Public Health Laboratory

25 Clinical indication & Risk behaviour Include information on ICE test request Symptoms No opposite sex partners 3/12 No same sex partners 3/12 New partner last year Condom used last episode SI Patient concerned at risk of an STI in last 3 mths Contact of : STI (name)

26 Unity Sexual Health 1 st June Dedicated website On-line postal testing Chlamydia, gonorrhoea, HIV syphilis Intelligent surveillance using geo-mapping Targeted digital health promotion geo-spatial and risk profiling Feedback to primary care Introduction targeted MG and TV testing On line advice about tests through Anglia ICE Risk based testing algorithms

27 Strengthening HIV testing in primary care Public Health Health protection and sexual health Slide 27

28 Prevalence of HIV in the UK, 2015 An estimated 107,800 people live with HIV in UK Overall prevalence 2.8 per 1000 population 24% unaware of status Prevalence is higher in certain communities Men who have sex with men 1 in 8 (London) 1 in 26 (UK) Black Africans 56 per 1000 population

29 Presentation title - edit in Header and Footer

30 HIV in the United Kingdom: 2014

31 Late diagnosis audit Audit found evidence of missed opportunities for earlier HIV diagnosis in Bristol practices Public Health Health protection and sexual health Slide 31

32 Prevalence rate per 1,000 aged HIV in Bristol Diagnosed prevalence rate is 2.14 per 1000 population aged 15 to 59 and is rising. Proportion of people presenting at a late stage of infection was 43% in and slowly improving (national average is 40%) Bristol South West England Public Health Health protection and sexual health Slide 32

33 HIV prevalence Bristol 0.21%

34 NICE Guidance on HIV Testing, Recommendations for GP Surgeries, December Offer and recommend HIV testing to everyone who: Has symptoms that may indicate HIV Discloses that they are at high risk of HIV (eg, men who have sex with men) In areas of high prevalence, offer and recommend HIV testing to everyone who: registers with the practice or is undergoing blood tests for another reason and has not had an HIV test in the previous year. Public Health Health protection and sexual health Slide 34

35 BHIVA guidance (2008) NICE guidance (2011)

36 Interventions to increase HIV testing in primary care Training in 20 high prevalence practices to increase knowledge and address barriers Screening pilot for newly registered patients in 6 highest prevalence practices Developing risk prediction algorithm tool which will flag when an HIV test might be appropriate Public Health Health protection and sexual health Slide 36

37 HIV in Bristol Public Health Health protection and sexual health Slide 37

38 Evaluating the impact of the training Questionnaire showed training was received positively. Gained more awareness of both BHIVA and NICE HIV testing guidelines and improved confidence around discussing and conducting an HIV test Interviews showed that some felt they had increased HIV testing others did not. Barriers include perceived lack of opportunity and considering HIV during consultations. Follow-up sessions were recommended. Assessing impact on HIV testing rates in practices that received the training Public Health Health protection and sexual health Slide 38

39 Screening pilot Offer to all new patients aged through written information which recommends who should have a test Those who accept make an appointment for a new blood test and written information provided Appointment with a trained HCA for a serology blood test (those unwilling can be redirected to another service) All positive results to be handled by a GP Public Health Health protection and sexual health Slide 39

40 How to test?

41 Explanation to patient Why are they being offered the test? Part of routine investigation for the condition they are suffering Higher prevalence in this area advised PHE Part of a higher risk group Benefits of knowing the test is negative Reassurance HIV can be excluded from differential diagnosis Benefits of knowing the test is positive Effective treatment available (life expectancy ~ normal) Earlier treatment = better prognosis HIV infection will impact upon treatment of other conditions Help avoid passing it on to current or future partners Discuss how to get results Emphasise confidentiality

42 10ml clotted blood Request on ICE New request > Microbiology > Virology/Serology > Blood for Virology/Serology > HIV screen This tests for HIV antibody and p24 antigen

43 What to do with the result?

44 Inform the patient It is good that they know, and action can be taken Refer to the HIV team Information on the Southmead website Patient information leaflet available

45 Acknowledgments Peter Muir Jane Nicholls Helen Wheeler Thara Raj Margaret May Megan Crofts Katy Turner