The implementation of systematic, frequent
and routine screening for sexually transmitted infections (STIs) led to a
significant increase in the number of infections detected among HIV-positive
people in London, investigators report in HIV
Medicine. Doctors and nurses caring for HIV-positive people were prompted
to carry out an annual STI screen by an electronic patient records system.
Many of the detected infections were asymptomatic. Incidence of chlamydia,
gonorrhoea and syphilis all increased significantly in gay men, and there was a
significant increase in incidence of chlamydia and trichomonas vaginalis among heterosexual people.
“Although some of these increases may be
attributable to a genuine increase in STI incidence, it is likely that better
diagnosis is responsible as a result of the introduction of prompts on our EPR
[electronic patient records] system to aid more systematic STI screening,”
write the authors.
Early detection and treatment of STIs in
people with HIV is important for two reasons: untreated infections increase
the risk of HIV transmission, even when someone is taking virologically
suppressive therapy; and some STIs, including syphilis and hepatitis C, can be
harder to treat in people with HIV.
Guidelines recommend that regular STI
screens should be incorporated into routine HIV care. Audits of clinical
practice in the UK and elsewhere suggest that screening often does not occur,
with testing rates as low as 46%.
Since 2008, hospitals in north-west London
have been using electronic medical records for their HIV-positive patients.
This includes an annual checklist, prompting healthcare professionals to
undertake certain investigations, including an annual STI screen.
Investigators wished to see how successful
they had been at diagnosing STIs in HIV-positive patients since the
introduction of the checklist.
They therefore designed a retrospective
study involving approximately 900 patients who received care between 2009 and
Data were gathered on STI incidence in
three concurrent twelve-month periods: 2009/10; 2010/11; 2011/12.
From the electronic records, the
investigators were able to establish that 90% of patients had an STI screen in
2009/10. This increased to 97% of patients in 2010/11.
The total number of people diagnosed with
an STI was 19 in 2009/10. This increased to 21 in 2010/11 and almost doubled
to 41 in 2011/10.
Infection rates in all three time periods
were significantly higher among gay men than in heterosexual people (p < 0.05).
In 2010/11, a total of 7 chlamydia
infections were diagnosed in gay men. This doubled to 14 in 2011/12 (p <
0.001), and nine of these infections were asymptomatic. The 100% increase in
chlamydia infections detected by the investigations was significantly higher
than the 10% increase seen among gay men nationally.
Diagnoses of gonorrhoea also more than doubled
in gay men between 2010 and 2012, from 5 to 12 infections (p < 0.05),
50% of which were asymptomatic. The investigators note that this increase in
gonorrhoea incidence outstripped the 10% annual rise seen in national
Diagnoses of early syphilis also increased
significantly from 4 to 13 infections (p < 0.0001). This increase
was against national trends, and the investigators suggest that their findings
are therefore likely to reflect local epidemiological conditions. However, they
believe their screening programme meant that diagnoses were made “several
months earlier than would have happened previously and may have prevented
progression to late stage disease”.
The use of the checklist did not lead to an
increase in the number of LGV infections diagnosed in gay men. Only two
infections were detected; one was asymptomatic, the other had mild symptoms.
Most LGV infections involve symptoms and it is therefore possible that
proactive screening led to the detection of infections which may otherwise have
“Another benefit of advanced screening is
that the anus is examined more frequently in a group of men at higher risk of
anal cancer,” comment the investigators.
The use of the electronic checklist led to
an increase in the detection of chlamydia infections among heterosexuals
(2010/11 = 4 vs 2011/12 = 13; p < 0.0001). Over the course of the
study, incidence of trichomonas vaginalis
among heterosexual patients increased from 0.1 per 100 person-years to 0.4
per 100 person-years.
“With a systematized approach to STI
screening using facilities inherent in EPR, we have dramatically increased the
rate of STI diagnoses in both MSM and heterosexual patients,” conclude the