Cheshire and Merseyside Sexual Health Network STI Care Pathways explanatory document

Transcription

1 Cheshire and Merseyside Sexual Health Network STI Care Pathways explanatory document

2 Clinical STI/HIV Care Pathway assumes appropriate competency verified (flow chart and explanatory notes to be read together) Network of services (NHS and non NHS) GUM 3 Reproductive and SH 1 or 2 CSO 1 or 2 General practice 1 or 2 Voluntary sector 1 Outreach 1 Walk-In Centres 1 or 2 Pharmacy 1 Symptoms or high risk Sexual Health Risk Assessment No symptoms and low risk HIV +ve Level 3 service All other conditions Men TMA urine test for GC & CT Women endocervical or self-taken vaginal swab (optimal) or TMA urine test for GC & CT Bloods for syphilis, Hep B and HIV (depending on venue) Support, Clinical assessments PN monitoring, Rx if required. Shared care with GP and Voluntary sector support. All according to national (BASHH, BHIVA & SSHA) and local HIV Network guidelines. Clinical assessment and management according to diagnosis Rx & PN and follow-up according to BASHH and SSHA guidelines where appropriate. HIV, Hep B, GC, STS +ve CT, GC +ve All results delivered to service user, preferably by text. All tests ve BASHH = British Association of Sexual Health & HIV BHIVA = British HIV Association SSHA = Society Sexual Health Advisers C&S = Culture and Sensitivity CT = Chlamydia GC = Gonorrhoea PN = Partner notification Rx = Treatment STS = Syphilis GC C&S (Level 2 only) Rx, PN, Per BASHH Exit No STI follow-up required if appropriate incubation periods passed Sexual Health Promotion to be provided at Levels 1, 2 and 3, and throughout patient s journey; to include free condoms, contraception advice as appropriate. All STI treatments to be provided free of charge. All agencies should participate in the appropriate surveillance and reporting systems and comply with The NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions 2000.

3 This document is intended for local commissioners and providers of sexual health services as guidance on recommended care for people accessing sexual health services in Cheshire and Merseyside. It is recommended that this document be reviewed biannually or earlier in the light of new evidence. There has been a tendency in recent years for STIs to be trivialised, but the reality is that there is nothing trivial about an STI, even where the condition is easily treated. Management includes treatment and support for the infected individual and also his/her sexual contact(s) and exclusion of other relevant conditions where appropriate. One of the aims of this piece of work is to de-stigmatise sexually transmitted infections, many of which are extremely common. Commissioners have the responsibility to ensure that effective systems are in place to safeguard the public as well as to promote equity, choice and improved access. In particular, that appropriate competencies are in place and that health care professionals (HCPs) conform to agreed national clinical guidelines. Publication of Department of Health guidance on verification of competencies in sexual health is awaited. Aims of Cheshire and Merseyside Sexual Health Network These are to promote: Empowering of service users Easy and prompt access to services Effective prevention Equitable, high quality standards of care Underlying Principles The Cheshire and Merseyside Sexual Health Network (CMSHN) advocates the development of sexual health care delivery of a uniformly high standard in Cheshire and Merseyside. This care must be based upon sound evidence and recognised best practice. The flow chart refers throughout to BASHH, BHIVA and SSHA for guidance and clinical governance. Mechanisms to support clinicians and reduce variations in practice also need to be in place in the non-gum setting. The care pathway for STIs needs to be underpinned by: 1 Choice for the individual to approach the service s/he feels appropriate for the problem. 2 Appropriate and verifiable competency of the health care professional (HCP) involved. 3 Effective inter-agency working/referral systems where these competencies are not in place. Competence This is the fundamental issue and inevitably a number of references in the attached guidance refer to competence, but in principle: a service user has the not unreasonable expectation that the HCP is competent to deal with the problem; the HCP has the duty to not work beyond his/her competence and to also work in ways that best serve patients interests. Public Health duties Sexual health care is characterised by HCPs having a combined individual and public health responsibility. There is also a requirement to comply with appropriate reporting and surveillance processes. Any HCP involved in the management of sexually transmitted infections is required to comply with the relevant legislation. Levels 1, 2 & 3 Although the flow chart directs those with symptoms to Level 3 services, some can be dealt with by HCPs working at Level 2. The real issue here is around competence, which would imply a long working relationship with Genitourinary Medicine (GUM), participation in audit and clinical governance processes etc. To try to tease this out would make the flow chart very long and complex and cause confusion.

4 The Levels explained Level 1 = Test initiators. Level 2 = Those services that provide treatments (e.g. for Chlamydia) and partner notification. Also initiate tests, i.e. Level 1. Level 3 = Those services that provide Levels 1 and 2, but also provide testing, treatment and partner notification for those with more complex STI conditions and HIV. Getting results to service users All service users should obtain a result and systems must be in place to ensure this. The detail of how this happens may depend on individual circumstances and patient preference. Bringing back patients for negative results should be strongly discouraged unless necessary on clinical grounds. In most circumstances, a face to face discussion is not needed as results can be delivered by telephone, text etc. Urine testing Urine testing for chlamydia in men is painless, in marked contrast to urethral swabs. The use of urine for the testing of chlamydia (with an appropriate test) should be strongly encouraged as urine is a sample that is suitable for widespread population screening. Urine testing for gonorrhoea in men is painless and can be done at the same time as the chlamydia test if using TMA. Research is currently being undertaken re the suitability of the urine TMA test for the screening of gonorrhoea. One thing is certain the urine TMA test for gonorrhoea is far better than no test at all and it appears to pick up many extra cases of gonorrhoea that otherwise would not have been identified. It may prove to be a good test for screening. However, the organism is not isolated (which is necessary for direct antibiotic sensitivity testing). Therefore, all patients with a positive TMA test on urine should be referred to a service with the facility to take appropriate samples, culture the organism and perform sensitivity testing. Urine testing for chlamydia in women recent evidence suggests that urine tested by TMA is equivalent to vulvo-vaginal swab or endocervical swab. Urine testing for gonorrhoea in women is not as good as a self-taken vulvo-vaginal swab and not as good as endocervical swabs taken by a trained HCP, but is far better than nothing. In summary: In asymptomatic men, a TMA chlamydia and gonorrhoea testing of urine only may be reasonable (with the difficult to quantify risk of missing an asymptomatic urethritis due to Mycoplasma genitalium) In men with symptoms of urethritis, TMA chlamydia and gonorrhoea testing of urine only would clearly be unsatisfactory. In women with vaginal, urethral, cervical or pelvic symptoms, a TMA chlamydia and gonorrhoea testing of urine only would be unsatisfactory. In asymptomatic women, a TMA chlamydia and gonorrhoea testing of urine only would be the next best option if both examination by an HCP with endocervical swabs or self-taken vulvo-vaginal swabs declined/unavailable. Mycoplasma Genitalium We do not currently have a readily available test to detect this organism, which causes a proportion of urethritis in men who have been found to be negative for both chlamydia and gonorrhoea. Their diagnosis is, therefore, non-specific urethritis (NSU). This is not a trivial infection because M.genitalium is linked with pelvic inflammatory disease. In other words, the future fertility of the past, current and future female sexual contacts of a man with NSU due to M.genitalium may depend on whether NSU is diagnosed in the first place. The current test for NSU is with a urethral swab NSU is NOT diagnosed by a urine TMA (Transcription Mediated Amplification) test for Chlamydia / gonorrhoea. That means that cases of M.genitalium urethritis / PID may be missed. There is debate about how much that matters, but it is possible that M.genitalium is a significant emerging pathogen, but there is a lack of robust evidence to guide us.

5 Lack of evidence/areas of uncertainty There are areas of missing evidence and this partly explains variations in clinical practice. In the event of robust evidence emerging, this document will need modification in the future (before the review date below). Dr Mike Abbott On behalf of Care Pathways Working Group Cheshire and Merseyside Sexual health Network Review date: 1 September 2008