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Sexually transmitted infections – safer sex

Key learning points:

– Signs and symptoms of common sexually transmitted infections

– Advice that primary care nurses can give to patients

– Training opportunities

Sexual health is an important area of public health as most of the adult population are sexually active within the United Kingdom. Providing accessible and more importantly, quality sexual health services is a significant aspect of improving the wellbeing of the population.1 In 2013, the Department for Health released the Framework for Sexual Health Improvement in England,2 which clearly lays out the Government’s ambitions for improving sexual health within England. Likewise, poor sexual health is not evenly spread within the population. There are significant links between deprivation and poor sexual health.3 Moreover, sexually transmitted infections continue to remain a significant public health concern with approximately 440,000 cases in 2014 within England alone.4

The Faculty of Sexual Health and Reproductive Healthcare and the British Association of Sexual Health and HIV provides detailed guidance on managing sexual health for patients. The Faculty of Sexual and Reproductive Healthcare Service Standards on Workload in Sexual and Reproductive Health acknowledges the considerable variation in sexual health service delivery within the UK. Services range from primary care/community-based contraceptive services that are separate from genitourinary medicine services and abortion services, to community based services which are fully integrated.5 It ‘recommends services, but not necessarily individual clinics, should be staffed by doctors, nurses and healthcare assistants with a variety of skills and working as a clinical team’.

The Faculty Service Standards for Sexual and Reproductive Healthcare (FSRH) support this further while clearly acknowledging enhanced nurse-led service provision.5 This article will discuss some of the common sexually transmitted infections and what advice primary care nurses should be giving to patients and training opportunities.

Bacterial infections

Chlamydia trachomatis is one of the most common sexually transmitted infections with approximately one-in-10 young sexually active people being thought to have the infection. It is a bacteria that is transmitted through sexual contact either vaginal, anal or oral intercourse. Uncomplicated chlamydia is easy to treat with a simple course of antibiotics either 1g Azithromycin – this is often given as a single dose when a patient presents in GU clinic or GP prescription if presenting in GP practice – or 100mg twice daily of Doxycycline. It is important to test and treat partners that may have been sexually exposed to the infection. Most laboratories will accept urine samples, cervical, urethral or self-taken vulvo-vaginal, rectal and pharyngeal swabs.6

Gonorrhoea is caused by intracellular bacteria Neisseria gonnorrhoeae and is more commonly seen in young people, those in large cities, black ethnic minority groups and men who have sex with men.4 Figures published in 2015 show a 19% increase in cases from 2013 to 2014 however this may be attributed to condomless sexual activity and better testing facilities.4 Uncomplicated Gonorrhoea can be treated with Ceftriaxone 500mg intramuscular injection and 1g of Azithromycin. It is important to test and treat all partners within the last 12 weeks that may have been exposed to the infection.7 More recently concerns have been raised about strains of gonorrhoea that have become resistant to antibiotics. The British Association for Sexual Health and HIV recommends culture testing on all patients diagnosed prior to treatment so that antibiotic susceptibility testing can be performed and resistant strains identified.7

Syphilis is a bacterial sexually transmitted infection transmitted through sexual contact, infected blood products, needle sharing and from mother to child (vertical transmission). It is most commonly seen in men who have sex with men within England and requires management from specialists within Genito-Urinary Medicine services. Syphilis is classified as either early or late infection, with early being within the first two years of becoming infected and late syphilis two years after becoming infected. Early syphilis is typically characterised by a single painless chancre (ulcer) that appears on the anogential tract from 10 – 90 days after infection. Within the first two years of infection syphilis typically disseminates around the body causing a generalised rash that often affects the palms of the hands and the soles of the feet. The rash will resolve on its own and is usually not itchy. Syphilis can then lead to symptomatic late infection affecting multiple body organs and can be a serious concern, although this is rarely seen within the UK. The British Association of Sexual Health and HIV provides The National Institute for Health and Care Excellence (NICE) accredited guidance on the management of syphilis infection.8

Viral infections

Genital warts are a common viral sexually transmitted infection caused by the human papilloma virus (HPV). There are thought to be more than 100 different types of HPV with strains 6 and 11 being mainly responsible for causing the small lumps or growths. They are usually not painful and patients access services after finding them on their genitalia. Warts appear either singular or multiple and can be soft or hard (keratinised). Most warts are harmless and treatment is performed for cosmetic reasons rather than to eradicate the HPV. Treatment varies but can include no treatment at all as the warts may resolve on their own, or cryotherapy (freezing), creams, surgical excision or rarely trichloracetic acid (TCA).9

Patients are often concerned that the genital warts they have are linked to cancer. It is important to reassure patients that genital warts are typically harmless and that it is strains 16 and 18 that are responsible for approximately 70% of squamous cell carcinoma of the cervix. Young females aged 12 to 13 are vaccinated against HPV with a quadrivalent vaccine including strains 6, 11, 16 and 18 (types 16 and 18 were only vaccinated against until recently). It is anticipated that a reduction in genital warts will be seen similar to what has happened in Australia, a country which has been using the quadrivalent vaccine since 2007.10 Herpes simplex virus (HSV) is a lifelong common sexually transmitted infection that is characterised by periods of inactivity and then reactivation. There are two types of HSV; HSV-1 and HSV-2 with both possible to cause genital infection. HSV-1 is typically contracted as a child and manifests as the oral cold sore virus affecting the mouth. HSV-2 is more traditionally connected with sexual transmission and infection in the anogenital region. Symptoms include painful genital blisters. Treatment includes oral antiviral medication (eg aciclovir or valaciclovir tablets), see the current British National Formulary (BNF) for accurate dosing.11

 

HIV

Human immunodeficiency virus (HIV) was first noted more than 30 years ago and has since developed from a life limiting infection to an infection that when detected early has significantly improved prognosis. It is estimated that there are currently around 107,800 people living with HIV in the UK, with approximately 80% of these aware of their diagnosis and accessing care.12 HIV has become a chronic manageable condition since the introduction of HIV antiretroviral medication (ART) to treat the infection. The life expectancy of people living with HIV who are being treated with ART is now comparable with someone who smokes, is obese or drinks excessive alcohol and due to this, the death rate has dramatically been reduced since the use of ART. HIV care is traditionally managed by a combination of sexual health medics and specialist nurses alongside the multidisciplinary team consisting of dieticians, psychologists and pharmacists.

Although life expectancy has increased and symptomology of HIV has been reduced since the introduction of ART, other metabolic changes have been seen in those living with HIV. Some of these changes include increased blood lipids, central fat accumulation, lipodystrophy, and decreased aerobic capacity.13 HIV can be transmitted by several different routes including sexual (oral, anal or vaginal sex), vertical transmission (mother to child) sharing injecting equipment, blood transfusion on unscreened products and finally occupational exposure. If HIV is not treated it will eventually develop into acquired immunodeficiency syndrome (AIDS) (advanced HIV) although with early and prompt treatment with ART it is possible to reverse some of the complications that AIDS cause. HIV testing is quick and easy with a simple blood test, so all clinical staff should feel comfortable to perform it. It is important to know where your HIV services are, so should you detect someone living with HIV you are then able to refer them promptly to the service.

Training for nurses

Primary care nurses need to have knowledge on sexually transmitted infections and may benefit from undertaking additional training at universities in sexual health such as CPD courses or the British Association of Sexual Health and HIV two day STIF (Sexually Transmitted Infections Foundation Theory) course. The STIF course14 has clear learning outcomes around knowledge, skills and attitudes:

Knowledge

– Describe the principles of STI service provision.

– Describe the issues relating to confidentiality, partner notification and treatment.

– Demonstrate basic knowledge of the epidemiology and the factors involved in the transmission of STIs and how to prevent transmission.

– Demonstrate basic knowledge of common STIs, their presentation, diagnosis and management.

– Describe when to refer patients.

Skills

– Demonstrate competence in taking a sexual history.

– Demonstrate the skills necessary to inform patients on reducing their risk of sexual infections and their risk of unplanned pregnancy.

– Optimise care pathways for patients through improved links with local GUM /sexual health (TOP, Contraception, psychosexual), and microbiology services.

Attitudes

– List the ways in which the lifestyle and circumstances of patients/clients may reflect in their presentation and impact on their management.

– Demonstrate an appreciation and acceptance of the range of human sexuality, lifestyles, culture and the impact this has on transmission/prevention counselling.

– Describe how one’s personal beliefs could affect the consultation.

Conclusion

As some of the sexually transmitted infections above do not have any symptoms it is important to consider regular sexual health screening regardless of age, gender and sexual orientation. If a patient is concerned or they have informed you they have had unprotected sex a routine test for sexually transmitted infections should be offered.

If the service you are working in does not offer this facility it would be useful to know where your local services are and refer the patient directly to the most suitable place.

References

1. Meek J, Brittain D, Dunnett K. The role of the HCA in sexual health services. British Journal of Healthcare Assistants 2014;8(10):489-495.

2. Department of Health. A framework for sexual health improvement in England, 2013. gov.uk/government/uploads/system/uploads/attachment_data/file/142592/9287-2900714-TSO-SexualHealthPolicyNW_ACCESSIBLE.pdf (accessed 15 June 2016).

3. Department of Health. Healthy Lives, Healthy People: Our Strategy for Public Health in England, 2010. dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_121941 (accessed 15 June 2016).

4. Public Health England. Infection Report. gov.uk/government/uploads/system/uploads/attachment_data/file/437433/hpr2215_STI_NCSP_v6.pdf (accessed 15 June 2016).

5. Faculty of Sexual and Reproductive Health. Service Standards for Sexual and Reproductive Healthcare, 2013. fsrh.org/pdfs/ServiceStandardsSexualReproductiveHealthcare.pdf (accessed 15 June 2016).

6. Nwokolo NC, Dragovic B, Patel S. UK National guidance for the management of infection with chlamydia trachomatis, 2015. bashh.org/documents/UK%20Chlamydia%20Guidelines%202015.pdf (accessed 15 June 2016).

7. Bignell C, Fitgerald M. UK national guideline for the management of gonorrhoea in adults, 2011. bashh.org/documents/3920.pdf (accessed 15 June 2016).

8. Kingston M, French P, Higgins S et al. UK national guidelines on the management of syphilis, 2015. bashh.org/documents/UK%20syphilis%20guidelines%202015.pdf (accessed 15 June 2016).

9. Nathan M, Sonnex C, Lazaro N et al. UK National Guidelines on the Management of Anogenital Warts, 2015. bashh.org/documents/UK%20national%20guideline%20on%20Warts%202015%20FINAL.pdf (accessed 15 June 2016).

10. Ali H, Donovan B, Wand H et al. Genital warts in young Australians five years into national human papillomavirus vaccination programme: national surveillance data. bmj.com/content/346/bmj.f2032 (accessed 15 June 2016).

11. Patel R, Green J, Clarke E et al. UK national guideline for the management of anogenital herpes, 2014. bashh.org/documents/HSV_2014%20IJSTDA.pdf (accessed 15 June 2016).

12. Public Health England. HIV in the UK 2015 Report. gov.uk/government/uploads/system/uploads/attachment_data/file/469405/HIV_new_diagnoses_treatment_and_care_2015_report20102015.pdf (accessed 15 June 2016).

13. Jaggers JR, Hand GA. Health Benefits of Exercise for People Living With HIV: A Review of the Literature. American Journal of Lifestyle Medicine 2014;20(10):1-9.

14. STIF. Learning outcomes. stif.org.uk/STIF/Home/STIF_Foundation/STIF/STIF_Foundation_Learning_Objectives.aspx (accessed 15 June 2016).