News from the frontline: sexually transmitted infections in teenagers attending a genitourinary clinic in south east London

Regional differences in chlamydia and gonorrhoeae positivity rate among heterosexual STI clinic visitors in the Netherlands: contribution of client and regional characteristics as assessed by cross-sectional surveillance data

OBJECTIVES

To assess to what extent triage criteria, client and regional characteristics explain regional differences in Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (Ng) positivity in sexually transmitted infection (STI) clinics.

DESIGN

Retrospective cross-sectional study on the Dutch STI surveillance database of all 24 STI clinics.

PARTICIPANTS

STI clinic visits of heterosexual persons in 2015 with a Ct (n=101 495) and/or Ng test (n=101 081).

PRIMARY OUTCOME MEASURE

Ct and Ng positivity and 95% CI was assessed for each STI clinic. Two-level logistic regression analyses were performed to calculate the percentage change in regional variance (PCV) after adding triage criteria (model 1), other client characteristics (model 2) and regional characteristics (model 3) to the empty model. The contribution of single characteristics was determined after removing them from model 3.

RESULTS

Ct positivity was 14.9% and ranged from 12.6% to 20.0% regionally. Ng positivity was 1.7% and ranged from 0.8% to 3.8% regionally. For Ct, the PCV was 11.7% in model 1, 32.2% in model 2% and 59.3% in model 3. Age, notified for Ct (triage), level of education (other characteristics) and regional degree of urbanisation (region) explained variance most. For Ng, the PCV was 38.7% in model 1, 61.2% in model 2% and 69.1% in model 3. Ethnicity (triage), partner in risk group, level of education and neighbourhood (other characteristics) and regional socioeconomic status (SES) explained variance most. A significant part of regional variance remained unexplained.

CONCLUSIONS

Regional variance was explained by differences in client characteristics, indicating that triage and self-selection influence positivity rates in the surveillance data.Clustering of Ng in low SES regions additionally explained regional variance in Ng; targeted interventions in low SES regions may assist Ng control. Including educational level as triage criterion is recommended. Studies incorporating prevalence data are needed to assess whether regional clustering underlies unexplained regional variance.

Seven years of teenage pregnancy in an inner London genitourinary medicine service - a retrospective cohort study

Young people attending genitourinary medicine services are at high risk of unplanned pregnancy. We performed a retrospective cohort study to identify characteristics of pregnant teenagers accessing an inner London genitourinary medicine service. There were 481 pregnancies in 458 teenagers with 54 previous pregnancies and 46 previous terminations of pregnancy. The under-18 and under-16 teenage pregnancy rates were 92.1 and 85.8 per 1000 age-matched clinic attendees, respectively. Median age was 17.1 years. 'Black Other' teenagers ('Black British', 'Mixed White-Black Caribbean' and 'Mixed White-Black African') were over-represented, compared to our clinic population, while those of White ethnicity were under-represented. Few pregnancies (1.5%) were planned with the majority (64%) intending terminations of pregnancy. Most teenagers did not use consistent contraception. Two-thirds of patients had attended genitourinary medicine services in the past and sexually transmitted infection prevalence at presentation was high. Effectively targeting the sexual and reproductive health needs of teenage genitourinary medicine clinic attendees may have a significant impact on reducing sexually transmitted infections, unplanned pregnancy and terminations of pregnancy in this group.

Depressive symptoms and behavioural health risks in young women attending an urban sexual health clinic

BACKGROUND

Adolescence is a time of increased health risk behaviours and depressive symptoms and disorders. Most young people with depressive disorders, however, are not under the care of specialist child and adolescent mental health services, and there is increasing interest in identifying alternative appropriate settings which are acceptable for young people and may attract those at high risk for depressive disorders.

AIM

To assess depressive and behavioural health risks in attendees to a sexual health clinic (SHC) for young people.

METHOD

Cross-sectional controlled study of women attending a SHC and school attendees, using questionnaires on depressive symptoms and mental health problems, sexual activity and substance use.

RESULTS

115/178 attendees 14-19 years old completed questionnaires. In the comparison between 66 women aged 16-18 years and 49 socio-demographically group-matched school controls, SHC attendees reported higher levels of sexual activity and substance use. They were significantly more at risk for depression (20/65 or 30% vs. 4/46 or 8%; chi(2)P < 0.01) on the Beck Depression Inventory, for emotional (12/66 or 18% vs. 1/49 or 2%; chi(2)P < 0.01), hyperactivity (11/66 or 16% vs. 2/46 or 4%; chi(2)P < 0.05) and conduct (8/66 or 12% vs. 0/49; chi(2)P < 0.05) problems on the Strengths and Difficulties Questionnaire. High depressive scores were significantly associated with a history of self-harm, earlier alcohol use and having tried cannabis, but not with sexual risk behaviours. Earlier age at first sexual intercourse was linked to higher sexual and substance use risks.

CONCLUSION

We have found high levels of depressive symptoms among attendees to a SHC for young people, which seem an appropriate setting for screening and providing guidance for depression and other health risk behaviours.

Management of under-16-year olds in UK genitourinary medicine clinics: British Co-operative Clinical Group

Summary:

In 2004, the management of under-16-year olds in UK genitourinary (GU) medicine clinics was surveyed. Questionnaires were sent to 185 lead GU medicine consultants. A total of 111 questionnaires were returned (60%). Ninety-eight percent of respondents managed young people aged 13-16. Fifty percent managed under 13-year-olds. Twenty-nine percent of respondents ran dedicated young people's clinics. Ninety-eight percent were aware of the National Guidelines, and 74%had adopted them. Fifty-seven percent had a named departmental child protection lead. Thirty-seven percent of consultants had received training specific to child protection issues in GU medicine. Improvements had been made since a similar survey published in 2001, but the need for further training was still apparent.

Impact of National Chlamydia Screening Programme on sexual health of children under the age of 16 years

The objectives of the study were to investigate the rates of sexually transmitted infections (STIs), uptake of full STI screening and contraceptive use during pre- and post National Chlamydia Screening Programme (NCSP) periods and to determine the prevalence of sexual abuse/assault. The method used was a retrospective case notes audit of children aged <16 years. STIs were found in 20% (n = 264) of children; 10% had genital chlamydia. 157 (59%) of 264 children had an assessment for non-consensual sexual activity; of those, 34% had a history of past or continuing sexual abuse/assault. An uptake of 'full STI screening' and contraceptive use were similar in both pre- and post-NCSP periods. Overall STIs and chlamydia rates were higher during post-NCSP period. In conclusion, NCSP has not yet made any significant impact on sexual health of under-16-year-olds and the prevalence of past or ongoing sexual abuse/assault was high.

One stop shop versus collaborative integration: what is the best way of delivering sexual health services?

OBJECTIVES

To examine various models of integrated and/or one stop shop (OSS) sexual health services (including general practice, mainstream specialist services, and designated young people's services) and explore their relative strengths and weaknesses.

METHODS

Literature review and interviews with key informants involved in developing the National Strategy for Sexual Health and HIV (n = 11).

RESULTS

The paper focuses on five broad perspectives (logistics, public health, users, staff, and cost). Contraceptive and genitourinary medicine issues are closely related. However, there is no agreement about what is meant by having "integrated" services, about which services should be integrated, or where integration should happen. There are concerns that OSSs will result in over-centralisation, to the disadvantage of stand alone and satellite services. OSS models are potentially more user focused, but the stigma that surrounds sexual health services may create an access barrier. From staff perspectives, the advantages are greater career opportunities and increased responsibility, while the disadvantages are concern that OSSs will result in loss of expertise and professional status. Cost effectiveness data are contradictory.

CONCLUSION

Although there is a policy commitment to look at how integrated services can be better developed, more evidence is required on the impact and appropriateness of this approach.

Psychological, Behavioral, and Interpersonal Impact of Human Papillomavirus and Pap Test Results

BACKGROUND

The purpose of this study was to explore the short-term psychological, behavioral, and interpersonal impact of human papillomavirus (HPV) and Pap results in adolescent and young adult women.

METHODS

Sexually active young women 14-21 years of age were recruited using a purposeful sampling strategy from a hospital-based teen health center. Participants underwent HPV DNA and Pap testing at baseline. At a follow-up visit 2 weeks later, they received test results and participated in individual interviews designed to examine the impact of test results. Interview data were analyzed using framework analysis, a qualitative analytical method.

RESULTS

The mean age of the 100 participants was 17.2 years, and 82% were black. Fifty-one percent were HPV positive, and 23% had abnormal Pap tests. Psychological responses consisted of affective reactions to abnormal results, empowerment through knowledge of results, and self-confidence to prevent future disease. Personal behavioral intentions encompassed safe sexual behaviors, partner monitoring, and return for screening. Anticipated interpersonal consequences focused on the impact of communication about test results on relationships. Psychosocial and behavioral responses were influenced by the personal meaning participants derived from HPV and Pap results (e.g., perceptions of personal risk and anticipated stigma), cognitive understanding of test results, and such factors as coping mechanisms, locus of control, and relationship quality.

CONCLUSIONS

An understanding of young women's responses to HPV and Pap test results may help guide clinical interventions designed to prevent possibly harmful psychosocial and interpersonal responses to HPV and Pap testing but promote healthy sexual behaviors and regular screening.

Biological and hormonal markers of chlamydia, human papillomavirus, and bacterial vaginosis among adolescents attending genitourinary medicine clinics

OBJECTIVE

To assess maturity indices, menstrual patterns, hormonal factors, and risk of adolescent genital tract infections.

METHODS

Cross sectional study in three genitourinary medicine clinics. Females 17 years or less, within 5 years of menarche, or reporting oligo-amenorrhoea were screened for genital tract infections and menstrual cycle characteristics determined. The outcome measures were risk factors associated with chlamydia, human papillomavirus (HPV DNA) and bacterial vaginosis (BV), separately and pooled. Correlations between estrone-3-glucuronide (E3G) and pregnanediol-3alpha-glucuronide (P3G) hormone concentrations and chlamydia, HPV, and BV.

RESULTS

Among 127 adolescents, HPV was present in 64.4% (95% CI: 54.5 to 74.3), BV in 33.9% (19.1 to 34.5), and chlamydia in 26.8% (19.1 to 34.5). Breast maturity, oligomenorrhoea, and older gynaecological age were associated with lower risk of all infections. After adjustment for calendar age, race, and behavioural factors, gynaecological age remained significant (OR = 0.7, 0.6-0.9; p = 0.008). Behavioural risk factors differed by infection. Smoking was protective for HPV (OR = 0.1, 0.0 to 0.9; p = 0.007), and a recent new partner for chlamydia (OR = 0.3, 0.1 to 0.9; p = 0.024). Sex during menses was associated with increased BV risk (OR = 3.3, 1.5 to 7.2; p = 0.003). Chlamydia was higher among adolescents who used emergency contraception (2.5; 1.1 to 5.9, p = 0.029) and lower among those using condoms at last sex (OR = 0.3, 0.1 to 0.9; p = 0.015). Among 25 adolescents not using hormonal contraceptives, 15 had disturbed or anovulatory cycles. Chlamydia risk was inversely associated with P3G concentrations (Mann-Whitney; p = 0.05).

CONCLUSIONS

Adolescents engaging in high risk behaviour at a young gynaecological age are susceptible to multiple infections. Adolescent clinical assessment should include gynaecological age.

The 374 clinic: an outreach sexual health clinic for young men

OBJECTIVES

To describe the establishment of a community based walk-in outreach genitourinary medicine clinic, the "374 clinic," in south London to target young men under 25 in an area with high rates of sexually transmitted infections (STIs).

METHODS

The outreach clinic was set up within a Brook advisory centre, which already had gained the trust of local young people. Epidemiological, clinical, and laboratory data were obtained retrospectively for the first 24 weeks of the service.

RESULTS

134 attendances were recorded, including 94 new and 10 rebook events. The age range of the young men seen was 12-27 years (mean 18.2 years), the patients were mainly from black and ethnic minority groups, and all but one were heterosexual. Most men had heard about the clinic by "word of mouth," recommendation by Brook staff or through clinic promotional material. Condoms were used more frequently with non-regular sexual partners than with regular partners. The uptake of screening for gonococcal and chlamydial infections, mostly by urine based molecular techniques, was 98%. The uptake for HIV testing in men aged 16 or more was 72%. An overall STI prevalence rate of 26% was detected in the clinic population, which consisted almost equally of asymptomatic and symptomatic patients. The most prevalent STI was chlamydial infection (12%).

CONCLUSIONS

The young men who attended the outreach clinic were happy to undergo both non-invasive urine based testing for gonorrhoea and chlamydia as well as phlebotomy to test for HIV and syphilis. The 374 clinic approach may prove to be a useful model for further outreach services to combat poor sexual health of young men in inner city areas.

Managing genital infection in community family planning clinics: an alternative approach to holistic sexual health service provision

OBJECTIVE

To pilot and evaluate sexually transmitted infection (STI) management in community family planning clinics (FPCs).

METHODS

Number of STI tests taken, positive results, infections treated, contacts traced/treated, referrals to specialist services and time from testing to treatment were documented as well as age and sex of the population tested.

RESULTS

STI tests taken increased from 233 to 308/month and male clients seen increased from 114 to 147/month across all clinics. Chlamydia prevalence rates in one large clinic increased from 6.7% to 11.9%. 82% of those with STIs in this clinic were treated. Of 44 clients treated for chlamydia, 84% had partner notification performed, 0.43 contacts were treated for every client with chlamydia and referrals to specialist services decreased. 70% of STIs were detected in clinic users under the age of 25 and 45.5% of clients tested under the age of 16 had an STI. Before STI treatment was available at FP clinics 52% of clients with STIs attended specialist services after referral and time from testing to treatment was 19 days. Managing STIs in the community increased treatment rates to 82% with a testing to treatment time of 10 days.

CONCLUSIONS

The management of uncomplicated genital infection in community FPCs working in partnership with specialist services is a feasible and effective approach to holistic sexual health service provision.

Prevalence of sexually transmitted infections and mental health needs of female child and adolescent survivors of rape and sexual assault attending a specialist clinic

OBJECTIVES

To determine the prevalence of sexually transmitted infections (STIs) and the mental health needs of female child and adolescent survivors of rape and sexual assault who were referred to a specialist genitourinary medicine (GUM) clinic.

METHOD

Retrospective case notes review of 98 females aged 16 or less, who attended over a 5 year period (1996-2000).

RESULTS

The overall prevalence of STIs was 26%. Among the girls who were aged 0-12 years (n = 16), one had gonorrhoea and another had Trichomonas vaginalis infection. Prevalence of STIs in those aged 13-16 years, who were not sexually active before the index assault, was 24% and in those who gave a history of previous consensual sexual activity it was 39% (p = 0.17). Chlamydial infection was more common among the girls who disclosed previous consensual sexual activity than in those did not disclose previous sexual activity (p = 0.012). The overall prevalence of vaginal candidiasis was 17% and bacterial vaginosis 13%. More than one third of the study population gave a history of previous sexual, physical, or other abuse. 81% reported having current psychological difficulties. Mood changes and sleep disturbances were reported more frequently than other psychological symptoms; 15% attempted self harm. All types of psychological difficulties, except mood changes, were not affected by the time interval between index assault and first presentation to the clinic and the type of assailant. 29% had no involvement with social and mental health services before their attendance at the clinic

CONCLUSIONS

The prevalence of STIs among female child and adolescent survivors of rape and sexual assault attending a specialist clinic was high. The range of mental health and social difficulties was wide and multiple. The importance of an early assessment for the presence of STIs and mental health difficulties was demonstrated.