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A profile of HIV and STI testing in primary care

Vicky Padbury
SRN ENB
Senior Nurse
Contraceptive and Sexual Health Service
East Surrey PCT

2006 was the 25th anniversary of the first reported case of acquired immunodeficiency syndrome (AIDS), and also the beginning of the surveillance of human immunodeficiency virus (HIV) in the UK by the Health Protection Agency (HPA). This article provides an update on the most recent figures we have on HIV and other sexually transmitted infections (STIs), and highlight the increasingly important role of the  primary care setting, which includes general practice and community contraceptive clinics, in both the testing and treating of clients who present with symptoms or who know they have put themselves at risk of acquiring an STI.

Sexual health - a high priority
In recent years the Department of Health (DH) has taken a wider approach for long-term improvements to sexual health, through initiatives such as the Sexual Health Strategy in 2001 which highlighted the long-term commitment to modernise and improve sexual health services,(1) and the continuing work of the Teenage Pregnancy Unit, which commenced in 1999 with the aim of reducing by half the under-18 teenage conception rate by 2010.(2) In 2004 the National Chlamydia Screening Programme (NCSP) was launched with the aim of reducing the rates of chlamydia in the under-25s.(3)
Such initiatives continued with the white paper Choosing Health in 2004, highlighting sexual health as one of the six key areas for health service development.(4)

A complex picture(5)
In 2005 HIV prevalence continued to increase steadily, with an estimated 63,500 adults (15-59 years) living with HIV in the UK, of whom 20,100 (32%) were unaware of their infection (see Table 1). There are many complex reasons for this continued increase:

  • Sustained levels of newly acquired infections in men who have sex with men (MSM).
  • Further diagnoses among heterosexual men and women who acquired their infection in Africa.
  • Improved survival since the availability of highly-active antiretroviral therapy (HAART).
  • Earlier and increased HIV testing, including antenatal screening.
  • Movements of populations particularly from sub-Saharan Africa.

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The concern to public health is those who are unaware of their HIV-positive status, as the disease has a prolonged "silent" period during which it often remains undiagnosed and the onward transmission continues. It is estimated that there are over 20,000 HIV-positive people in the UK who are unaware of their HIV status, whose blood has been tested under the Unlinked Anonymous Prevalence Monitoring Programme (UAPMP). This programme began in 1990 with the aim to measure the distribution of unrecognised (undiagnosed) infection in accessible groups attending GUM clinics. The legal and ethical basis for unlinked anonymous HIV testing was established before the programme began, and continues to provide valuable information for the targeting of health promotion, the evaluation of preventive measures, and the planning of medical and social services for those affected by HIV.

High-risk groups
The numbers of diagnoses among different groups of people is seen in Table 1. The greatest rise in numbers is among heterosexuals; many of these diagnoses were in black and minority ethnic adults (see Figure 1).(5)

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Men who have sex with men (MSM)
The group at greatest risk of acquiring HIV within the UK continues to be MSM. The re-emergence of syphilis has revealed a complex association between syphilis and HIV, and high-risk sexual behaviours.(5)

Injecting drug users (IDUs)
HIV rates among IDUs remain low compared with IDUs in other countries, but prevalence has remained elevated in London (3.2%), and outside of London prevalence has risen from 0.5% in 2003 to 1.2% in 2005. This may be linked to the varying standards of provision in regard to needle exchange (NEX) services in different areas of the country.

Black and minority ethnic populations (BME)
The global HIV epidemic continues to adversely affect BME populations in the UK. During 2005, nearly two-thirds of all new diagnoses (where ethnicity was reported) were among BME individuals, four-fifths of which were among black Africans, the majority of who probably acquired their infection in sub-Saharan Africa. Tuberculosis  is now one of the most common AIDS defining illnesses reported among this group of people.(5)

Antenatal screening for HIV
One important milestone in 2000 was the implementation of the screening of women for HIV during their routine antenatal care,6 on an opt-out basis. In 2005, one in every 450 women giving birth in England and Scotland was HIV-infected, with an estimated 95% of them being diagnosed before delivery, compared with about 83% in 2001 (see Figure 2).

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The benefits of early diagnosis include:

  • The use of antiretroviral treatments (ARVs) can be commenced at the appropriate time both for the mother's benefit and to help reduce the onward transmission of the virus in utero.
  • Health promotion in regard to being HIV positive can be shared.
  • The need to have a caesarean section birth (to reduce the risk of transmission via blood during a vaginal delivery) can be discussed and prepared for.
  • Advice and counsel on the importance of not breastfeeding can be given, as the virus is contained within breastmilk.
  • To help women who have a negative result remain negative.

NICE guidelines
In February 2007, the National Institute for Health and Clinical Excellence (NICE) published guidance on one-to- one interventions to reduce the transmission of sexually transmitted infections including HIV, and to reduce the rate of under-18 conceptions, especially among vulnerable and at-risk groups.(7) The guidance highlights at-risk groups, and suggests which professionals should be working with them, in both reducing risk-taking lifestyles, and if appropriate testing and treating individuals. The strong message in this document is that this kind of work is not site specific, and it is recommended that such work is carried out within:

  • GUM services.
  • GP practices.
  • Community health services that include contraceptive clinics.
  • School clinics.
  • Voluntary and community organisations.

Other sexually transmitted infections
The number of new diagnoses for 2005 show:

  • An overall rise in the number of all diagnoses made in GUM clinics in the UK of 3% (from 768,339 cases in 2004 to 79,387 in 2005).
  • A rise in chlamydia of 5% (from 104,840 in 2004 to 109,958 in 2005).
  • A rise in syphilis of 23% (from 2,282 in 2004 to 2,814 in 2005).
  • A rise in the number of cases of genital warts of 1% (from 80,082 in 2004 to 81,203 in 2005).
  • A rise in the number of cases of genital herpes of 4% (from 19,074 in 2004  to 19,771 in 2005).
  • A fall in the number of cases of gonorrhoea of 13% (from 22,321 in 2004 to 19,392 in 2005).

Chlamydia remains the most commonly diagnosed STI, with 109,832 new cases in 2005, and the highest rates of infection and highest increases in diagnoses seen for both sexes in the 16-24 age group (see Figure 3).

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Some of the increases we are seeing may reflect the greater availability of noninvasive and more sensitive methods of screening for chlamydia which would otherwise remain undiagnosed. The overall trend of increasing numbers is not the full picture as surveillance figures are collected only from GUM services. STIs diagnosed in the primary care setting, including community contraceptive clinics, are not being monitored at the moment.

The primary care setting
The primary care setting is where the majority of the public access advice, diagnostic procedures, treatment and appropriate onward referral. Practice nurses see large numbers of the public daily via new registrations, holiday vaccination appointments, contraceptive consultations, and so on, and subsequently have the opportunity to raise sexual health issues, lifestyle risk assessments and, if appropriate, offer a basic sexual health service - that is, a "level-one service" (see Boxes 1 and 2).

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The information in this update possibly makes the situation look challenging and complex, but it is hoped that having looked more closely at prevalence and high-risk groups it might become more apparent how we in the primary care setting can improve the numbers of people being screened for HIV and STIs, and intervene at earlier stages when the control and management of acute infections is more beneficial for both the individual and the health economy.

Issues to consider
Testing for chlamydia
We can now be more confident when offering tests for chlamydia, as we have highly sensitive swabs such as nucleic acid amplification testing swabs (NAATS), which can be self-taken as a vaginal swab and have a high specificity for accuracy.

HIV testing
There is an urgent need to be more proactive in offering/discussing HIV testing in primary care and issues such as the practice's policy on confidentiality should be considered and any gaps in training/updating of staff addressed.

Counselling
One reason why many healthcare professionals do not offer testing is due to the concern over the concept of pretest "counselling". The Global Programme on AIDS defines HIV/AIDS counselling as:
"A confidential dialogue between a client and a care provider aimed at enabling the client to cope with stress and take personal decisions related to HIV/AIDS. The counselling process includes an evaluation of personal risk and facilitation of preventative behaviour."(8)
The discussion should not take any longer than a normal consultation, and verbal consent should be given just like any other investigation.

Conclusion
The delivery of sexual health services must be via a flexible multidisciplinary workforce in a range of settings, where staff are sensitive to the particular needs of their local populations. Greater and improved access to GUM clinics and further developing the role of the primary care sector are vital in the control and management of acute STIs.
HIV is a complex chronic medical condition that necessitates careful monitoring. The large increase in the number of persons living with HIV requires a coordinated multiagency approach to the management and care of such individuals.

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References

  1. Department of Health. The national strategy for sexual health and HIV. London: DH; 2001.
  2. Department of Health The national teenage pregnancy strategy. London: DH; 1999.
  3. Department of Health. The national chlamydia screening programme (NCSP) in England. London: DH; 2004.
  4. Department of Health. Choosing health: making health choices easier. London: DH; 2004.
  5. Health Protection Agency. A complex picture: HIV and other STIs in the UK. Overview. London: HPA; 2006. Available from: http://www.hpa.org.uk
  6. The UK Collaborative Group for HIV and STI Surveillance. HIV and pregnant women. 2005. Available from: http://www.hpa.org.uk   
  7. NICE. Preventing sexually transmitted infections and reducing under 18 conceptions. Public health guidance 1003. London: NICE; 2007. Available from: http://www.nice.org.uk
  8. Centers for Disease Control Prevention. Questions and answers for the general public: revised recommendations for HIV testing of adults, adolescents and pregnant women in healthcare settings. Available from: http://www.cdc.gov./hiv/topics/testing