Dr Jeni Worden discusses how recent guidance will help primary care tackle the problems of STIs and under 18 conceptions in the UK
It is generally agreed that sexual health in the UK has deteriorated over the past 12 years, with large rises apparent in the detection of sexually transmitted infections (STIs). Chlamydia is diagnosed in genitourinary medicine clinics at a rate over 300% higher than in 1995 (32,288 cases in 1995 compared with 104,155 in 2004), and gonorrhoea over 200% higher (from 10,580 in 1995 compared with 22,335 in 2004).1 In addition, there has been an almost 300% increase in diagnosed cases of HIV (from 2500 in 1995 compared with more than 7000 in 2005).2
Overall, the conception rates for teenagers aged under 18 and under 16 years in England have fallen by 11.1% and 15.2%, respectively,3 since the introduction of the Teenage Pregnancy Strategy in 1999.4 However, the UK still has the highest teenage pregnancy rate in Western Europe.3,5
Prevention and treatment of sexually transmitted infections
Despite numerous public health initiatives, it is apparent that there is still more to be achieved in prevention and treatment of STIs.
Traditionally, GPs have considered the prevention and treatment of STIs as a role undertaken by clinics and specialists in genitourinary medicine. The difficulties in tracing partners of patients with STIs has, in the past, proved this to be an area better tackled using the resources available to centres of secondary care than by a GP practice nurse. Similarly, the prevention of under 18 conceptions has been considered to be appropriate to the roles of family planning clinics (FPCs) and schools, which offer pupils advice on contraception as part of their sex education programmes. However, the guideline published by NICE in February 2007 on the prevention of STIs and under 18 conceptions places these two very important public health issues well within the capacity of most GPs.3
What are the guideline recommendations?
The NICE guideline makes six recommendations: three on the prevention of STIs, two specifically focusing on conceptions in those under 18 years of age, and one on ensuring that PCTs have sexual health services in place (see Box 1).3
Recommendations 1 and 5 (see Box 1) are the most relevant to the ordinary GP in everyday practice. The other recommendations focus on actions to be taken by other professionals in the primary care team, including health visitors, midwives, and GPs with a special interest in sexual health. So how should these recommendations be implemented?
Box 1: Recommendations from the NICE guideline3
1. Identify those individuals whose sexual history puts them at high risk of contracting an STI, to carry out a risk assessment (such as during consultations on contraception, pregnancy, STI test, or travel requirements), and to have or arrange for structured discussions with the patient on maintaining their sexual health.
2. Discuss with high-risk individuals the possibilities for instituting behaviour changes that will reduce that risk of STI infection (such as avoiding alcohol/substance abuse and unprotected sex).
3. Assist patients with an STI in getting their partners tested, and treated if necessary, including notifying partners; to provide information on the infection and risk of reinfection (perhaps providing a kit for home testing for chlamydia infection).
4. PCTs should ensure sexual health services are in place, with a clearly defined role for each service, including providing staff training, and should also have an effective audit and monitoring scheme.
5. Providing vulnerable teenagers under 18 years of age (such as those from disadvantaged backgrounds, young people in or leaving care homes, and those who have low levels of education) with advice on sexual health, including prevention of STI infection and pregnancy, and advice on reversible and emergency contraception.
6. Regularly visiting vulnerable young women under 18 years of age who are pregnant or already mothers to discuss prevention of STIs and unwanted pregnancies, including discussion of contraception, postnatal care, and possibilities for returning to work or education.
Implementation of guidance on STIs
Clinical research has shown that advice from GPs, such as that on using condoms for STI prevention, is a cost-effective way of controlling the spread of these diseases.3 Many GPs discuss sexual health issues when offering contraceptive advice. Counselling is not always offered to those people who are planning travel to countries, including some in the Far East, Third World, and emerging Western European countries, where incidence of STIs and AIDS is high.6–8 While there, some travellers may engage in risky sexual behaviour.
Opportunistic counselling when providing travel advice is specifically mentioned in the new guideline,3 and is an area my practice will be reviewing in our next audit of our nurse-led travel clinics.
In order to raise the general awareness about STIs, advertisements are now placed on television and kits are available for self-testing for chlamydia infection from high street pharmacies. However, one of the groups at greatest risk from STI infection, men who have sex with men, still appears to be ignoring the message on prevention measures. In addition, people who have multiple partners and those who have unprotected sex appear to be similarly ignorant. It is to be hoped that implementation of these guidelines will produce a resulting reduction in the rates of infections.
Opportunistic advice is often relatively straightforward in general practice as patients are often seen on more than one occasion, which is not the case for specialist services in secondary care. Patients are often wary of their sexual orientation being formally documented on the practice medical record computer system as a friend or neighbour working at the practice may see that information in the course of their employment. The relative anonymity of the genitourinary medicine (GUM) clinic may encourage such information to be given, and records are not passed on to a GP's practice unless the patient specifically requests this to be done.
Under 18 conceptions
Research has shown that girls from disadvantaged backgrounds, those with low educational achievement, or who are in or leaving local authority care appear to be the most at risk of becoming pregnant before the age of 18 years.3
In the Ringwood area in Hampshire, the local FPCs and GP practices encourage all methods of contraception, including long-acting reversible contraception,9 in accordance with the NICE guideline. Nevertheless, it is still possible to meet teenage girls who ask you how they will know if the morning after pill has not worked. To the vulnerable under 18 year old, taking a risk sometimes seems acceptable and they find it difficult to talk to a GP on such a sensitive matter. Inevitably, an attitude of 'hoping for the best' prevails. It is important, therefore, for GPs to help these teenagers understand that they are able to access primary healthcare of a confidential nature.
Lifestyle and sexual health advice for patients under 18 years
Researchers in this field have suggested that settings in primary care may be more acceptable to young people seeking advice on sexual health.10In the Ringwood area, the local FPC has a 'Young Person's Clinic', targeted at the under 18s, based in one of the GP practices. Another local practice operates a system whereby a teenager wishing to seek advice, not just on sexual health but on other lifestyle issues, such as drugs or alcohol, passes a card to the receptionist on arrival. This alerts the receptionist to the sensitive nature of the consultation needed and an appointment is made to see either a practice nurse or GP with expertise in this area, usually for that day. The cards are distributed via youth clubs and youth workers, or are available from public buildings, such as the local library. This seems to be working well so far and it will be interesting to see what results an outcome study in progress shows.
By at least ensuring that young people are getting the best possible advice about safer sex, hopefully, there will be a reduction in unplanned and unwanted pregnancies.
Partner notification can be difficult in primary care as partners may not be registered in the same practice or even the same PCT as the contact. This is recognised in the NICE guideline under recommendation 3, which is directed to health professionals or specialists working in GP, GUM, and community health services, including GPs providing enhanced sexual health services. At present, it is something that most GPs have to leave to the GUM specialist services.
SummaryThe NICE guideline contains clear recommendations; for example, recommendation 1 (Box 1) indicates four situations when the GP could undertake simple one-to-one interventions. This is very helpful when they are also trying to ensure that the consultation covers any areas that are needed to acquire QOF points for the practice, as well as meeting the patient's needs, concerns, and expectations.
- The NICE long-acting reversible contraception costing template predicts savings of around £8 for £1 invested1
- Adolescents often prefer ‘drop in’ services away from their parent’s registered practice
- PBC could look to provide extra contraceptive and sexual health services to patients of many practices in a convenient location
- Pharmacists are well placed to help deliver post-coital contraception, advice and screening services
- Tariff prices: genitourinary medicine outpatient = £146 (new), £811 (follow-up)2
- Health Protection Agency and The UK Collaborative Group for HIV and STI Surveillance. Mapping the issues. HIV and other sexually transmitted infections in the United Kingdom: 2005. London: HPA, 2005.
- Health Protection Agency and Health Protection Scotland (2006a) Quarterly surveillance tables No 70 06/1 Table 3a [online]. Available from: www.hpa.org.uk/infections/topics_az/hiv_and_sti/hiv/epidemiology/files/2006_Q1_Mar_HIV_Quarterlies.pdf
- National Institute for Health and Care Excellence. One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups. NICE Public Health Intervention Guidance 3. London: NICE, 2007.
- Social Exclusion Unit. Teenage pregnancy. London: HMSO, 1999.
- Teenage Pregnancy Unit. Under 18 conception data for top tier local authorities LAD1 1998Ð2004. Available from: www.dfes.gov.uk/teenagepregnancy/ [accessed 8 August 2006].
- Kmietowicz Z. Aids in Russia—glasnost comes at last. Br Med J 2006; 332 (7551): 1176.
- Deayton J, French P. Incidence of early syphilis acquired in former Soviet Union is increasing. Br Med J 1997; 315 (7114): 1018–1019.
- Rogstad K. Sex, sun, sea and STIs: sexually transmitted infections acquired on holiday. Br Med J 2004; 329 (7459): 214–217.
- National Institute for Health and Care Excellence. Long acting reversible contraception. Clinical Guideline 30. London: NICE, 2005.
- Tripp J, Viner R. Sexual health, contraception, and teenage pregnancy. Br Med J 2005; 330 (7491): 590–593.G