Many sexual health clinic attenders have unnecessary tests and visits, say doctors in debate

Sexual health services in the UK are overstretched, and radical change which cuts the length of patient waiting times, reduces the number of visits an individual needs to make to a clinic, and delegates health care to other providers, should be considered say two senior doctors from a London sexual health clinic.

In a debate on the future of the UK’s sexual health services in the December edition of Sexually Transmitted Infections, Drs Bradbeer and Mears of St Thomas’s Hospital and King’s College Hospital suggest that many asymptomatic patients do not need to be examined by a doctor, that tests for bacterial sexually transmitted infections (STIs) using a microscope are often useless, that for many patients outside high risk groups, blood tests for HIV and syphilis are a waste of time, and that primary care, and eventually community pharmacists, should offer testing and treatment for a bacterial STI such as chlamydia.

Replying to these suggestions, Dr Chris Carne of of Addenbrooke’s Hospital in Cambridge, however, stresses the value of examining asymptomatic patients, using microscope tests for bacterial STIs, and routine syphilis testing.

Outlining the need to review the way sexual health services are provided, the doctors from south London highlight the three or four hour waiting times in their open-access sexual health clinics. Time could be saved, they suggest, by replacing the taking of a full sexual history and physical examination of asymptomatic patients with a questionnaire. Further, as microscope tests often fail to detect bacterial infections in both men and women, and patients often leave the clinic falsely believing their test results are negative, only results based on cultures should be used, with patients receiving test results by post.

The use of oral HIV tests could increase uptake of HIV testing, and by testing only patients from high risk groups for syphilis, the need to routinely test the blood of all sexual health clinic patients would be avoided, thereby saving time. If a patient does have a blood test for HIV, then time could be saved by training health advisers, who offer pre-test counselling, to take blood.

Further time could be saved by cutting down on return visits. The value of treating genital warts is questioned, and return visits for test of cure “may be unnecessary”, say the authors, adding “we know our drugs work and we know that most of those with failed treatment have been reinfected.”

Results, even HIV test results, do not always need to be given in person, say the south London doctors, noting “in the case of HIV results many clinicians remain reluctant to abandon giving the result in person. However, in these days of patient choice we believe it is patronising to insist that they return to receive their results in person.”

Nurse specialists should be allowed to do a greater amount of routine testing and diagnosis in clinics, suggest the authors, with consultants or specialist registrars only seeing complicated cases. Primary care could become more involved in the treatment of STIs, and the authors envisage a situation when community pharmacists will sell new NAAT tests for chlamydia and, under protocol driven directives, be allowed to prescribe azithromycin treatment.

Replying to these suggestions, Dr Chris Carne stresses the importance of examining a patients, whether symptomatic or not. The examination, he argues, serves to build trust, and failure to examine a patient who had genital warts could be counterproductive “to ensuring the emotional, physical, and mental well-being that goes to make up sexual health.”

Addressing Drs Bradbeer’s and Mears’s comments on the value of routine microscope tests for bacterial STIs, Dr Carne notes that a large percentage of patients who claim to be asymptomatic will subsequently admit to having symptoms after an STI has been diagnosed.

There is some agreement on HIV testing, with Dr Carne suggesting that only patients at high risk of the disease or who are very anxious should be encouraged to receive their test results in person. As regards routine syphilis testing, however, Dr Carne notes that the index case of syphilis in a recent outbreak was an asymptomatic heterosexual who refused a syphilis test, and that 174 cases of syphilis in 2000 were in heterosexuals.

Although follow-up appointments for test of cure may not always be needed, they can serve as useful occasions for patient education. However, Dr Carne supports the south London doctors’ suggestion that primary care should become more involved in sexual health.

Further information on this website

UK’s sexual health in crisis, say MPs