2012 BASHH statement on partner notification for sexually transmissible infections

Sexual health behaviours and partner notification practices related to sexually transmitted infections in young adults in Ireland

BACKGROUND

Sexually transmitted infections (STIs) impose burdens on individuals and communities, while their prevalence in young people has risen continually in recent years. Partner notification is an effective public health strategy which can limit STI transmission.

AIMS

This study aimed to explore young adults' sexual health behaviours, attitudes toward STI testing, and feelings toward visiting a sexual health clinic. It also aimed to investigate preferences for partner notification and the role of self-efficacy in people's intentions to notify a partner for STIs including the human immunodeficiency virus (HIV).

METHODS

A quantitative, cross-sectional design was applied. Participants were 400 adults aged 18-34 years (M = 23 years; SD = 4.27), recruited from the Republic of Ireland.

RESULTS

Over half of the participants reported never being tested for STIs. These young people placed less importance on undergoing regular STI testing and testing after unprotected sex than their counterparts who had been tested for STIs. Self-efficacy was significantly associated with intentions to notify partner(s) for STIs including HIV.

CONCLUSIONS

As STIs are becoming increasingly prevalent in young adults, it is important to gain a deeper understanding of the interventions used to break the transmission chain and how different beliefs and attitudes may affect them. Self-efficacy was a key component in PN intentions, suggesting that the belief in someone's ability or skillset to perform a sexual health behaviour is positively related to their intention to perform the behaviour.

Sexual partner referral and associated factors among patients with sexually transmitted disease in Jabi Tehnan district and Finote Selam town

BACKGROUND

Partner referral (or contact tracing) is an essential approach for preventing sexually transmitted infections. Even though this approach has been used in Ethiopia, there is a scarcity of evidence in Ethiopia particularly in this study area.

METHODS

A cross-sectional study was conducted among 397 patients with curable sexually transmitted diseases. Factors associated to the practice of sexual partner referral were explored where variables having a p-value of <0.05 in multivariable analysis were considered statistically significant.

RESULT

Referrals for sexual partners were found to be 42.4% in this study (95% CI: 35.3, 45.3). Not expecting the end of the relationship among regular partnerships (AOR: 4.8; 95% CI: 1.9, 12.4), perceived risk of reinfection (AOR: 3.0; 95% CI: 1.8, 5.3), perceived self-efficacy (AOR: 3.8; 95% CI: 2.4, 6.3), intention to refer partners (AOR: 3.7; 95% CI: 2.0, 6.4), and knowledge of sexually transmitted infections (AOR: 3.0; 95% CI: 1.8, 5.0) were significantly associated with sexual partner referral.

CONCLUSIONS

This study showed that sexual partner referral was low. Perceived risks of reinfection, perceived self-efficacy, anticipating the end of a relationship, intention to refer partners, and knowledge of sexually transmitted infections were significant predictors of sexual partner referral. Intervention endeavors need to consider factors pointed out in this study to improve sexual partner referral.

Assessing complex interventions: a systematic review of outcomes used in randomised controlled trials on STI partner notification in high-income countries

BACKGROUND

Partner notification interventions are complex and assessing their effectiveness is challenging. By reviewing the literature on the effectiveness of partner notification interventions, our aim was to evaluate the choice, collection, and interpretation of outcomes and their impact on study findings.

METHODS

We conducted a systematic review of individual-level randomised controlled trials evaluating the effectiveness of partner notification interventions for bacterial STIs, HIV or sexually transmitted HCV in high-income countries since 2000. Partner notification interventions included assisted patient referral interventions and expedited treatment. The content analysis was carried out through a narrative review.

RESULTS

In the 9 studies that met the inclusion criteria, 16 different outcomes were found. In most studies, one or two outcomes assessing partner notification practices were associated with an outcome reflecting STI circulation through index case reinfections. These outcomes assessed the main expected effects of partner notification interventions. However, partner notification is composed of a succession of actions between the intervention on the index case and the testing and/or treatment of the notified partners. Intermediate outcomes were missing so as to better understand levers and barriers throughout the process. Potential changes in participants' sexual behaviour after partner notification, e.g. condom use, were outcomes reported in only two studies assessing interventions including counselling. Most outcomes were collected through interviews, some weeks after the intervention, which might lead to desirability and attrition biases, respectively. Assessment of the effectiveness of partner notification interventions on partner testing/treatment was limited by the collection of data from index cases. Few data describing index cases and their partners were provided in the studies. Additional data on the number and type of exposed partners and the proportion of partners already aware of their infection before being notified would help to interpret the results.

CONCLUSIONS

These insights would help to understand why and under what conditions the intervention is considered effective and therefore can be replicated or adapted to other populations and contexts.

Optimising partner notification outcomes for bacterial sexually transmitted infections: a deliberative process and consensus, United Kingdom, 2019

Partner notification (PN) is an essential element of sexually transmitted infection (STI) control. It enables identification, treatment and advice for sexual contacts who may benefit from additional preventive interventions such as HIV pre- and post-exposure prophylaxis. PN is most effective in reducing STI transmission when it reaches individuals who are most likely to have an STI and to engage in sexual behaviour that facilitates STI transmission, including having multiple and/or new sex partners. Outcomes of PN practice need to be measurable in order to inform standards. They need to address all five stages in the cascade of care: elicitation of partners, establishing contactable partners, notification, testing and treatment. In the United Kingdom, established outcome measures cover only the first three stages and do not take into account the type of sexual partnership. We report an evidence-based process to develop new PN outcomes and inform standards of care. We undertook a systematic literature review, evaluation of published information on types of sexual partnership and a modified Delphi process to reach consensus. We propose six new PN outcome measures at five stages of the cascade, including stratification by sex partnership type. Our framework for PN outcome measurement has potential to contribute in other domains, including Covid-19 contact tracing.

Treponema pallidum PCR testing for diagnosis of mucocutaneous ulcers suspicious for syphilis

BACKGROUND

Primary syphilis is characterised by the appearance of an ulcerated lesion (chancre) on the anogenital or oral mucosa from which Treponema pallidum DNA may be detectable by PCR. Serological tests for syphilis may be non-reactive in early infection, even after the appearance of a chancre. We reviewed the use of a multiplex-PCR (M-PCR) test to determine the added value of T. pallidum DNA detection in the management of individuals presenting with mucocutaneous ulceration at a sexual health service in central London.

METHODS

We performed a cross-sectional analysis of all individuals with detectable T. pallidum DNA from September 2019 to April 2020. Electronic patient records were reviewed and concomitant results for treponemal serology and/or rapid plasma reagin (RPR) extracted, along with demographic data, history of syphilis and indices of sexual behaviour including number of sexual partners contacted. Any subsequent treponemal serology and RPR results were also reviewed.

RESULTS

M-PCR swab specimens were performed in 450 individuals, of whom 63 (14%) had detectable T. pallidum DNA; 60 of 63 (95%) were gay or bisexual men and 11 of 63 (17%) were living with HIV. A history of treated syphilis was present in 17 of 63 (27%). Same-day treponemal serology/RPR testing was performed in 58 of 63 (92%) patients. Of the 58 who had same-day syphilis serology/RPR, 9 (16%) had their syphilis infection confirmed by treponemal DNA PCR alone. A total of 165 partners were traced as contacts of infection, of whom 25 (15%) were contacts of individuals diagnosed by M-PCR testing alone.

CONCLUSION

In individuals with T. pallidum PCR-positive lesions, around one in six in our cohort were negative on standard diagnostic serological tests for syphilis. Treponemal DNA testing is an important addition to serological assays in individuals with mucocutaneous ulceration who are at risk of recent syphilis infection and facilitates early diagnosis and contact tracing.

Analysis of chlamydia contacts and the look-back interval at a UK sexual health clinic

Guidance on contact tracing in Chlamydia trachomatis (CT) is limited. CT contacts data over 12 months (1 December 2018-29 November 2019) at a UK sexual health clinic were analysed to determine the appropriateness of the currently recommended six-month 'look-back' interval. Age and sex of CT contacts were associated with clinical outcomes. Subgroups of 100 CT positive/negative contacts (each N = 100) were randomly selected. The relationship between time since sexual intercourse with the index case (Last Sexual Intercourse; LSI) and CT positivity was examined; suitability of varying look-back intervals was explored. Of 891 CT contacts (mean age = 25.0 years, 66.2% men), 66.9% tested positive for CT. Positive CT contacts were significantly younger (23.8 ± 6.8 years vs. 27.4 ± 9.1, p < 0.001) and more often women (36.4% vs. 28.5%, p = 0.018) than negative contacts. In the subgroups, the Mann-Whitney U test revealed no significant difference between the LSI of positive and negative contacts (p = 0.081). 95% of positive CT contacts (N = 82) were captured within a hypothetical three-month look-back interval. While most CT positive contacts were captured within three months, they appeared to remain proportionately represented beyond this point. Although this supports current guidelines, further research should investigate whether CT contacts involved in longer look-back intervals may require disproportionately greater resources to trace.

Managing contacts of chlamydia: should clinics implement a test and wait process?

British guidelines recommend epidemiological treatment for all chlamydia contacts during the look back period. Some UK sexual health clinics follow a test and wait process for chlamydia contacts presenting after 14 days of exposure. The aim of this retrospective service evaluation was to determine the potential impact of implementing such a process for chlamydia contacts at our clinic. We reviewed the patient records of 548 chlamydia contacts over a 1-year period, and 588 patients with chlamydia over a 5-month period. Demographic and clinical characteristics data were collected.Chlamydia prevalence was 46% (254/548) in contacts, with prevalence varying by age (p=.008) and sexual risk (p=.04), but not by time since exposure (p=.29). For patients with chlamydia, there was a mean of 1.9 days between results notification and attending for treatment; a mean of 2.2 attempts were required to contact patients to return for treatment. Chlamydia prevalence in contacts is high. Not giving empirical treatment to contacts presenting after 14 days of exposure would result in 13.1% of the cohort needing to return for treatment. Patients found to have chlamydia returned promptly once informed of positive results.

Increase in Gonorrhea Incidence Associated With Enhanced Partner Notification Strategy

OBJECTIVES

Partner notification services for reportable sexually transmitted infections vary based on jurisdiction, resources, type of infection, and whether an outbreak has been reported. The objective of this study was to determine whether case finding increased after implementation of enhanced notification and follow-up activities for contacts of cases of Neisseria gonorrhoeae in Central Zone, the largest health authority in Nova Scotia, Canada.

METHODS

Enhanced contact tracing by public health professionals was implemented in May 2015. N. gonorrhoeae multiantigen sequence typing (NG-MAST) was conducted on all positive specimens. Epidemiologic and NG-MAST information for reported gonorrhea cases were captured and analyzed. Case numbers, rates, and NG-MAST results in the preintervention and postintervention periods were compared. Laboratory testing data were extracted and analyzed for association with reported incidence.

RESULTS

There was a significant increase in the number of reported gonorrhea cases per month when comparing the preintervention and postintervention periods. The reported gonorrhea rate in 2016 was 2.9 times that in 2014. This increase was not associated with changes in testing rates and was more pronounced among women than men. Larger groups of cases sharing the same NG-MAST profiles were detected postintervention.

CONCLUSIONS

The implementation of an enhanced contact tracing program for N. gonorrhoeae resulted in increased case finding and a notable increase in the reported rate of cases per 100,000 population. Owing to these findings, the practice of enhanced partner notification was continued as standard public health practice in Central Zone. An understanding of case finding efforts is required when interpreting observed trends in rates of N. gonorrhoeae, as early infection is highly asymptomatic in women and can be asymptomatic in men.

Addressing Gaps in the Management of Chlamydia trachomatis and Neisseria gonorrhoeae in Primary Care: Lessons Learned in a Pilot Intervention Study

BACKGROUND

We aimed to test the acceptability and utility of strategies designed to facilitate the delivery of clinical best practice for patients diagnosed with chlamydia or gonorrhea in primary care.

METHODS

A nonrandomized pilot intervention study with a historic control period was run over 9 months in six primary health care clinics (2 youth services, 3 low-fee clinics, and 1 student health service) in Wellington, New Zealand. "Study nurses" in participating clinics oversaw the implementation of strategies designed to facilitate partner notification and follow-up for patients diagnosed with chlamydia or gonorrhea. Clinics chose which of 2 approaches they wished to trial-either managing all study processes themselves or drawing on the assistance of an external specialist sexual health advisor. Outcome measures included acceptability and utility of study processes ascertained via structured interviews with study nurses and collection of clinical data.

RESULTS

Outcomes for 287 patients seen during the intervention were compared with 240 historic controls. Participant views on study processes were positive overall, and all clinics intended to continue all or most of the study processes implemented. During the intervention, substantial improvements were observed in documented patient management (sexual history, partner notification, and outcomes, P < 0.05). Increases were observed in percentages of patients reached for follow-up (74% vs. 26% at baseline, P < 0.05) and partners reported to have been notified (79% vs. 23%, P < 0.05).

CONCLUSIONS

Nurse-led strategies implemented were deemed acceptable and appeared to facilitate delivery of best practice care for patients diagnosed with bacterial sexually transmitted infections in participating primary care practices.

Accelerated partner therapy (APT) partner notification for people with Chlamydia trachomatis: protocol for the Limiting Undetected Sexually Transmitted infections to RedUce Morbidity (LUSTRUM) APT cross-over cluster randomised controlled trial

INTRODUCTION

Partner notification (PN) is a process aiming to identify, test and treat the sex partners of people (index patients) with sexually transmitted infections (STIs). Accelerated partner therapy (APT) is a PN method whereby healthcare professionals assess sex partners, by telephone consultation, before giving the index patient antibiotics and STI self-sampling kits to deliver to their sex partner(s). The Limiting Undetected Sexually Transmitted infections to RedUce Morbidity programme aims to determine the effectiveness of APT in heterosexual women and men with chlamydia and determine whether APT could affect Chlamydia trachomatis transmission at population level.

METHODS AND ANALYSIS

This protocol describes a cross-over cluster randomised controlled trial of APT, offered as an additional PN method, compared with standard PN. The trial is accompanied by an economic evaluation, transmission dynamic modelling and a qualitative process evaluation involving patients, partners and healthcare professionals. Clusters are 17 sexual health clinics in areas of England and Scotland with contrasting patient demographics. We will recruit 5440 heterosexual women and men with chlamydia, aged ≥16 years.The primary outcome is the proportion of index patients testing positive for C. trachomatis 12-16 weeks after the PN consultation. Secondary outcomes include: proportion of sex partners treated; cost effectiveness; model-predicted chlamydia prevalence; experiences of APT.The primary outcome analysis will be by intention-to-treat, fitting random effects logistic regression models that account for clustering of index patients within clinics and trial periods. The transmission dynamic model will be used to predict change in chlamydia prevalence following APT. The economic evaluation will use mathematical modelling outputs, taking a health service perspective. Qualitative data will be analysed using interpretative phenomenological analysis and framework analysis.

ETHICS AND DISSEMINATION

This protocol received ethical approval from London-Chelsea Research Ethics Committee (18/LO/0773). Findings will be published with open access licences.

TRIAL REGISTRATION NUMBER

ISRCTN15996256.

Improved results demonstrated in the 2017 national audit of early syphilis management in the United Kingdom

The revised British Association of Sexual Health and HIV UK guidelines on the management of syphilis were published in 2015 and this audit measures performance against those standards and recommendations. Although not included in the guideline recommendations, an exploratory question on clinics’ HIV testing policy was also included. The audit was conducted over a two-month period in 2017 in genitourinary medicine (GUM) clinics across the UK of cases presenting in 2016. A total of 161 GUM clinics participated, and data were collected for 3017 cases. The standard for adherence to recommended treatment was met (97%, standard: 97%) and almost met for documented pre-treatment syphilis serology (95%, standard: 97%). Even though only 74% of patients had a documented action in relation to informing sexual contacts (standard: 97%), the standard for contacts seen and tested per index case within four weeks was met (0.9, standard: 0.6). Finally, those clinics with a formal policy on HIV testing after a syphilis diagnosis were twice as likely to test after the HIV window period, compared to clinics without a policy; a concurrent HIV diagnosis was made in 75 (3%) patients. More work is required to standardize documented delivery of effective partner notification and a formal policy on HIV testing appears to be effective.

Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020

This report (hereafter referred to as STD QCS) provides CDC recommendations to U.S. health care providers regarding quality clinical services for sexually transmitted diseases (STDs) for primary care and STD specialty care settings. These recommendations complement CDC's Sexually Transmitted Diseases Treatment Guidelines, 2015 (hereafter referred to as the STD Guidelines), a comprehensive, evidence-based reference for prevention, diagnosis, and treatment of STDs. STD QCS differs from the STD Guidelines by specifying operational determinants of quality services in different types of clinical settings, describing on-site treatment and partner services, and indicating when STD-related conditions should be managed through consultation with or referral to a specialist. These recommendations might also help in the development of clinic-level policies (e.g., standing orders, express visits, specimen panels, and reflex testing) that can facilitate implementation of the STD Guidelines. CDC organized the recommendations for STD QCS into eight sections: 1) sexual history and physical examination, 2) prevention, 3) screening, 4) partner services, 5) evaluation of STD-related conditions, 6) laboratory, 7) treatment, and 8) referral to a specialist for complex STD or STD-related conditions.CDC developed the recommendations by synthesizing relevant, evidence-based guidelines and recommendations issued by other experts; reviewing current practice in the United States; soliciting Delphi ratings by subject matter experts on STD care in primary care and STD specialty care settings; discussing the scientific evidence supporting the proposed recommendations at a consultation meeting of experts and institutional stakeholders held November 20, 2015, in Atlanta, Georgia; conducting peer reviews of draft recommendations and supporting evidence; and discussing draft recommendations and supporting evidence during meetings of the CDC/Health Resources and Services Administration Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment STD Work Group. These recommendations are intended to help health care providers in primary care or STD specialty care settings offer STD services at their clinical settings and to help the persons seeking care live safer, healthier lives by preventing and treating STDs and related complications.

Clinician education, advice and SMS/text reminders improve test of reinfection rates following diagnosis of Chlamydia trachomatis or Neisseria gonorrhoeae: before and after study in primary care

BACKGROUND

Evidence-based guidelines for the management of Chlamydia trachomatis and Neisseria gonorrhoeae recommend testing for reinfection 3-6 months following treatment, but retesting rates are typically low.

METHODS

Participants included six primary care clinics taking part in a pilot study of strategies designed to improve partner notification, follow-up and testing for reinfection. Rates of retesting between 6 weeks and 6 months of a positive chlamydia or gonorrhoea diagnosis were compared across two time periods: (1) a historical control period (no systematic approach to retesting) and (2) during an intervention period involving clinician education, patient advice about reinfection risk reduction and retesting, and short messaging service/text reminders sent 2-3 months post-treatment inviting return for retesting. Retesting was calculated for demographic subgroups (reported with 95% CI).

RESULTS

Overall 25.4% (61 of 240, 95% CI 20.0 to 31.4) were retested during the control period and 47.9% (116 of 242, 95% CI 43.2 to 55.1) during the intervention period. Retesting rates increased across most demographic groups, with at least twofold increases observed for men, those aged 20-29 years old, and Māori and Pasifika ethnic groups. No significant difference was observed in repeat positivity rates for the two time periods, 18% (11 of 61) retested positive during the control and 16.4% (19 of 116) during the intervention period (p>0.05).

CONCLUSIONS

Clinician and patient information about retesting and a more systematic approach to follow-up resulted in significant increases in proportions tested for reinfection within 6 months. These simple strategies could readily be implemented into primary healthcare settings to address low rates of retesting for bacterial sexually transmitted infections.

TRIAL REGISTRATION NUMBER

ACTRN12616000837426.

Pathways to, and use of, sexual healthcare among Black Caribbean sexual health clinic attendees in England: evidence from cross-sectional bio-behavioural surveys

BACKGROUND

In England, people of Black Caribbean (BC) ethnicity are disproportionately affected by sexually transmitted infections (STI). We examined whether differences in sexual healthcare behaviours contribute to these inequalities.

METHODS

We purposively selected 16 sexual health clinics across England with high proportions of attendees of BC ethnicity. During May-September 2016, attendees at these clinics (of all ethnicities) completed an online survey that collected data on health service use and sexual behaviour. We individually linked these data to routinely-collected surveillance data. We then used multivariable logistic regression to compare reported behaviours among BC and White British/Irish (WBI) attendees (n = 627, n = 1411 respectively) separately for women and men, and to make comparisons by gender within these ethnic groups.

RESULTS

BC women's sexual health clinic attendances were more commonly related to recent bacterial STI diagnoses, compared to WBI women's attendances (adjusted odds ratio, AOR 3.54, 95% CI 1.45-8.64, p = 0.009; no gender difference among BC attendees), while BC men were more likely than WBI men (and BC women) to report attending because of a partner's symptoms or diagnosis (AOR 1.82, 95% CI 1.14-2.90; AOR BC men compared with BC women: 4.36, 95% CI 1.42-13.34, p = 0.014). Among symptomatic attendees, BC women were less likely than WBI women to report care-seeking elsewhere before attending the sexual health clinic (AOR 0.60, 95% CI 0.38-0.97, p = 0.039). No ethnic differences, or gender differences among BC attendees, were observed in symptom duration, or reporting sex whilst symptomatic. Among those reporting previous diagnoses with or treatment for bacterial STI, no differences were observed in partner notification.

CONCLUSIONS

Differences in STI diagnosis rates observed between BC and WBI ethnic groups were not explained by the few ethnic differences which we identified in sexual healthcare-seeking and use. As changes take place in service delivery, prompt clinic access must be maintained - and indeed facilitated - for those at greatest risk of STI, regardless of ethnicity.

2016 United Kingdom national guideline on the sexual health care of men who have sex with men

This guideline is intended for use in UK Genitourinary medicine clinics and sexual health services but is likely to be of relevance in all sexual health settings, including general practice and Contraception and Sexual Health (CASH) services, where men who have sex with men (MSM) seek sexual health care or where addressing the sexual health needs of MSM may have public health benefits. For the purposes of this document, MSM includes all gay, bisexual and all other males who have sex with other males and both cis and trans men. This document does not provide guidance on the treatment of particular conditions where this is covered in other British Association for Sexual Health and HIV (BASHH) Guidelines but outlines best practice in multiple aspects of the sexual health care of MSM. Where prevention of sexually transmitted infections including HIV can be addressed as an integral part of clinical care, this is consistent with the concept of combination prevention and is included. The document is designed primarily to provide guidance on the direct clinical care of MSM but also makes reference to the design and delivery of services with the aim of supporting clinicians and commissioners in providing effective services. Methodology This document was produced in accordance with the guidance set out in the BASHH CEG's document 'Framework for guideline development and assessment' published in 2010 at http://www.bashh.org/guidelines and with reference to the Agree II instrument. Following the production of the updated framework in April 2015, the GRADE system for assessing evidence was adopted and the draft recommendations were regraded. Search strategy (see also Appendix 1) Ovid Medline 1946 to December 2014, Medline daily update, Embase 1974 to December 2014, Pubmed NeLH Guidelines Database, Cochrane library from 2000 to December 2014. Search language English only. The search for Section 3 was conducted on PubMed to December 2014. Priority was given to peer-reviewed papers published in scientific journals, although for many issues evidence includes conference abstracts listed on the Embase database. In addition, for 'Identification of problematic recreational drug and alcohol use' section and 'Sexual problems and dysfunctions in MSM' section, searches included PsycINFO. Methods Article titles and abstracts were reviewed and if relevant the full text article was obtained. Priority was given to randomised controlled trial and systematic review evidence, and recommendations made and graded on the basis of best available evidence. Piloting and feedback The first draft of the guideline was circulated to the writing group and to a small group of relevant experts, third sector partners and patient representatives who were invited to comment on the whole document and specifically on particular sections. The revised draft was reviewed by the CEG and then reviewed by the BASHH patient/public panel and posted on the BASHH website for public consultation. The final draft was piloted before publication. Guideline update The guidelines will be reviewed and revised in five years' time, 2022.

Should we screen for the sexually-transmitted infection Mycoplasma genitalium? Evidence synthesis using a transmission-dynamic model

There is increasing concern about Mycoplasma genitalium as a cause of urethritis, cervicitis, pelvic inflammatory disease (PID), infertility and ectopic pregnancy. Commercial nucleic acid amplification tests (NAATs) are becoming available, and their use in screening for M. genitalium has been advocated, but M. genitalium's natural history is poorly-understood, making screening's effectiveness unclear. We used a transmission-dynamic compartmental model to synthesise evidence from surveillance data and epidemiological and behavioural studies to better understand M. genitalium's natural history, and then examined the effects of implementing NAAT testing. Introducing NAAT testing initially increases diagnoses, by finding a larger proportion of infections; subsequently the diagnosis rate falls, due to reduced incidence. Testing only symptomatic patients finds relatively little infection in women, as a large proportion is asymptomatic. Testing both symptomatic and asymptomatic patients has a much larger impact and reduces cumulative PID incidence in women due to M. genitalium by 31.1% (95% range:13.0%-52.0%) over 20 years. However, there is important uncertainty in M. genitalium's natural history parameters, leading to uncertainty in the absolute reduction in PID and sequelae. Empirical work is required to improve understanding of key aspects of M. genitalium's natural history before it will be possible to determine the effectiveness of screening.

European guideline for the management of pediculosis pubis

Pediculosis pubis is caused by Phthirus pubis. The disease can be sexually transmitted. Patients main complain is of itch in the pubic area. The parasite can be spotted with the naked eye and blue macules can be observed in the pubic area. First line therapy consists of permethrin or pyrethrins with piperonyl butoxide. Second line therapy contains phenothrin, malathion and oral ivermectin. Partner management needs a look-back period of time of 3 months. Pubic lice incidence is increased in populations groups living in crowded spaces with scarce sanitary conditions as in time of war or disaster.

European guideline for the management of scabies

Scabies is caused by Sarcoptes scabiei var. hominis. The disease can be sexually transmitted. Patients' main complaint is nocturnal itch. Disseminated, excoriated, erythematous papules are usually seen on the anterior trunk and limbs. Crusted scabies occurs in immunocompromised hosts and may be associated with reduced or absent pruritus. Recommended treatments are permethrin 5% cream, oral ivermectin and benzyl benzoate 25% lotion. Alternative treatments are malathion 0.5% aqueous lotion, ivermectin 1% lotion and sulphur 6-33% cream, ointment or lotion. Crusted scabies therapy requires a topical scabicide and oral ivermectin. Mass treatment of large populations with endemic disease can be performed with a single dose of ivermectin (200 micrograms/kg of bodyweight). Partner management needs a look-back period of 2 months. Screening for other STI is recommended. Patients and close contacts should avoid sexual contact until completion of treatment and should strictly observe personal hygiene rules when living in crowded spaces. Written information should be provided to suspected cases.

Tracing partners of patients with syphilis infection remains challenging: experience of Geneva Hospital

Syphilis has been reinstated on the list of notifiable diseases in Switzerland since 2006 and the active management of sexual partners is encouraged to avoid reinfection. However, contact tracing has yielded unsatisfactory results and the incidence of syphilis remains important, especially in high-risk populations. The aim of this study was to compare the proportions of notified sexual partners of patients diagnosed with syphilis by the laboratories of Geneva University Hospitals (HUG) with those diagnosed in private laboratories (non-HUG) and to assess the risk factors for no notification to sexual partners. All syphilis cases notified to the Office of the Surgeon General in Geneva (Switzerland) between 1 January 2011 and 31 December 2013 were analysed. The proportions of partner notification (PN) between HUG and non-HUG laboratories were compared by Chi square test and the main risk factors for no notification to sexual partners were assessed by binomial log-linear regression. Among a total of 720 notifications reported, 244 cases were diagnosed with contagious syphilis stages and 263 with non-contagious stages (i.e. successfully treated patients with or late latent cases). Overall, PN was higher among contagious than non-contagious cases (58.4% versus 31.0%; p = 0.030) and it was significantly higher in the non-HUG compared to the HUG group (75.9% versus 50.0%, respectively; p < 0.001). Risk factors independently associated with no notification to sexual partners were the place of diagnosis (risk ratio [RR] 1.66; 95% confidence interval [CI] 1.21-2.27 for HUG versus non-HUG, respectively), age >45 years (RR 1.36; 95% CI: 1.05-1.76) and if the patient had received treatment for syphilis (RR 1.91; 95% CI: 1.38-2.66). Our results illustrate the difficulty of contact tracing in syphilis infection and the necessity to improve this crucial part of sexually transmitted infection management.

Partner Services in Sexually Transmitted Disease Prevention Programs: A Review

BACKGROUND

Partner services have been a mainstay of public health sexually transmitted disease (STD) prevention programs for decades. The principal goals are to interrupt transmission and reduce STD morbidity and sequelae. In this article, we review current literature with the goal of informing STD prevention programs.

METHODS

We searched the literature for systematic reviews. We found 9 reviews published between 2005 and 2014 (covering 108 studies). The reviews varied by study inclusion criteria (e.g., study methods, geographic location, and infections). We abstracted major conclusions and recommendations from the reviews.

RESULTS

Conclusions and recommendations were divided into patient referral interventions and provider referral interventions. For patient referral, there was evidence supporting the use of expedited partner therapy and interactive counseling, but not purely didactic instruction. Provider referral through Disease Intervention Specialists was efficacious and particularly well supported for HIV. For other studies, modeling data and testing outcomes showed that partner notification in general reached high-prevalence populations. Reviews also suggested more focus on using technology and population-level implementation strategies. However, partner services may not be the most efficient means to reach infected persons.

CONCLUSIONS

Partner services programs constitute a large proportion of program STD prevention activities. Value is maximized by balancing a portfolio of patient and provider referral interventions and by blending partner notification interventions with other STD prevention interventions in overall partner services program structure. Sexually transmitted disease prevention needs program-level research and development to generate this portfolio.

The eClinical Care Pathway Framework: a novel structure for creation of online complex clinical care pathways and its application in the management of sexually transmitted infections

BACKGROUND

Despite considerable international eHealth impetus, there is no guidance on the development of online clinical care pathways. Advances in diagnostics now enable self-testing with home diagnosis, to which comprehensive online clinical care could be linked, facilitating completely self-directed, remote care. We describe a new framework for developing complex online clinical care pathways and its application to clinical management of people with genital chlamydia infection, the commonest sexually transmitted infection (STI) in England.

METHODS

Using the existing evidence-base, guidelines and examples from contemporary clinical practice, we developed the eClinical Care Pathway Framework, a nine-step iterative process. Step 1: define the aims of the online pathway; Step 2: define the functional units; Step 3: draft the clinical consultation; Step 4: expert review; Step 5: cognitive testing; Step 6: user-centred interface testing; Step 7: specification development; Step 8: software testing, usability testing and further comprehension testing; Step 9: piloting. We then applied the Framework to create a chlamydia online clinical care pathway (Online Chlamydia Pathway).

RESULTS

Use of the Framework elucidated content and structure of the care pathway and identified the need for significant changes in sequences of care (Traditional: history, diagnosis, information versus Online: diagnosis, information, history) and prescribing safety assessment. The Framework met the needs of complex STI management and enabled development of a multi-faceted, fully-automated consultation.

CONCLUSION

The Framework provides a comprehensive structure on which complex online care pathways such as those needed for STI management, which involve clinical services, public health surveillance functions and third party (sexual partner) management, can be developed to meet national clinical and public health standards. The Online Chlamydia Pathway's standardised method of collecting data on demographics and sexual behaviour, with potential for interoperability with surveillance systems, could be a powerful tool for public health and clinical management.

Sexually acquired reactive arthritis

Sexually acquired reactive arthritis (SARA) may present acutely to general physicians. It is important to consider the condition and to identify key features in the history and examination so that appropriate investigations are taken and optimum treatment is given. Involvement of relevant specialists in the management is essential and where sexually transmitted infections are identified, partner notification is required.

2015 European guidelines for the management of partners of persons with sexually transmitted infections

BACKGROUND

Partner management is the process of identifying the contacts of a person infected by a sexually transmitted infection (STI) and referral to a health care provider for appropriate management. It represents a public health activity.

METHODS

This guideline is produced by the IUSTI European Guideline Editorial Board and EDF Guideline Committee.

RESULTS

It provides recommendations concerning the infections that require partner management, the lookback periods for this STI and the main steps to follow for partner management (offering support to patients, notifying partners, identification of contacts). Partner management is voluntary and needs to be performed with respect to human rights, social, cultural and religious behaviours.

CONCLUSIONS

In European countries, there are different approaches to the partner management; some common type of actions can enhance the fight against STI.

A survey of the use of text messaging for communication with partners in the process of provider-led partner notification

OBJECTIVES

Partner notification (PN) is important for sexually transmitted infection (STI) control. With developments in technology, such as text messaging, contacting partners is now easier. This study investigates the frequency and acceptability of text messaging in UK sexual health clinics for STI provider-led PN.

METHODS

A questionnaire was distributed to health advisers (HAs), cascaded by the Society of Sexual Health Advisers and posted on their website.

RESULTS

65 questionnaires were returned. Most HAs use telephone for the first and second provider-led PN attempt (61, 94% and 51, 78%, respectively) with text messaging as preferred second choice (19, 29% and 32, 49%, respectively). Overall, 56 clinics (86%) used text messaging at some stage, even if not the preferred option. 29 (52%) clinics had text messaging guidelines and 31 (55%) used messaging templates. Messages varied; 33 (59%) request partner make contact, 11 (20%) mention risk of infection, 9 (16%) name the infection and 20 (36%) use a combination of messages. Six (10%) had contact with their Caldicott Guardian about text messaging. No confidentiality concerns were reported and no complaints were reported from partners about receiving unsolicited text messages.

CONCLUSIONS

Text messaging is widely used and is an important and acceptable tool for STI provider-led PN. It is the second preferred method for contacting partners after telephone for first and second provider-led PN attempts. A small number of clinics never use it. Message content varied; few named the infection. Concerns about confidentiality or negative impact for the partner were not reported. National guidance for the use of text messaging for provider-led PN is needed.

Partner notification

Partner notification is an essential part of case management for sexually transmitted infections. Done correctly it reduces persistent or recurrent infection in the index patient, identifies previously undiagnosed infections, and may thus contribute to reduced transmission in the population. The effectiveness of patient referral of partners can be enhanced through the provision of written information and easy access to tests and medication. A recent systematic review of partner notification found that enhanced partner therapy (helping get treatment to partners more rapidly) reduced re-infection in the index case by almost 30% compared with simple patient referral. Provider referral, where the healthcare worker contacts partners directly, can also be effective, and provides an important service for patients who are wary of informing partners themselves. Partner notification services should be available for all patients found to have a sexually transmitted infection, whether the diagnosis is made in specialist settings, or in primary or community-based care. For patients with HIV, partner notification should be addressed when the infection is first diagnosed and revisited for subsequent partners. Access to specialist partner notification services is an important part of any sexual healthcare system. The professional competencies required to undertake partner notification have now been clearly defined.

Rectal Chlamydia in heterosexual women: more questions than answers

The aim of this study was to observe the proportion of concurrent rectal Chlamydia (RCt) infection in women who have cervical Chlamydia (CCt) and to observe whether there was any correlation with receptive anal intercourse (RAI). Untreated CCt-positive women were invited to take part. Women chose either to have a physician-collected or self-taken rectal swab. Treatment was then commenced. 17 samples were physician-collected and 80 were self-collected. 75/97 (77.3%, 95% Confidence Interval [95%CI] 69.0–85.7%) were RCt positive. 25/97 (25.8%, 95%CI 17.1–34.5%) reported RAI. There was no difference in the positivity rate whether RAI was reported (80%) or not (76%) ( P = 0.71); or whether swabs were physician-collected (65%) or self-taken (80%) ( P = 0.17). Only one of those with RCt reported rectal symptoms. One woman had concurrent gonococcal infection. 34/97 (35%) had a history of past sexually transmitted infections. Verified contact attendance was 0.52 and 72% of verified contacts were Chlamydia positive. Reported RAI may not be helpful in guiding RCt testing. RCt infection in women may be more prevalent than previously thought. We do not know whether RCt infections are clinically significant or whether they may act as a reservoir for re-infection. RCt infections in women require further study.