IUSTI guidelines on the organization of a consultation for STIs
The International Union against Sexually Transmitted Infections, IUSTI has released guidelines for the organization of consultation for sexually transmitted infections. This guideline is an update of 2012 version of IUSTI guideline and has been published in Journal of European Academy of Dermatology and Venereology.
This guideline is primarily focused at services provided in mainstream clinic/office environments, but increasingly many countries are seeing an era of rapid transition of sexual health services in which satellite clinics and online service provision are centre stages.
The following staff groups are essential in the smooth running of a facility managing patients presenting with sexually transmitted infections (STIs).
- ‐Nursing – qualified and support assistants
- ‐Medical staff – physicians from various medical disciplines might be involved in such consultations (gynecology, genito‐urinary medicine (GUM), dermatology, dermato‐venereology, reproductive and sexual health (RSH), infectious diseases, family medicine/general practice, urology, forensic medicine)
- ‐Laboratory staff to process relevant investigations
The following staff can provide additional services and benefits to such a clinic
- ‐Research team
- ‐Health advisors/contact tracers – or other appropriately trained personnel to assist in the process of partner notification, health promotion and risk reduction
Confidentiality and other ethical considerations
- The particular vulnerability of patients attending a clinic that tests for and/or treats STIs demands strict confidentiality.
- When taking a sexual history in a non‐confidential environment, encrypted devices should be considered for recording sensitive patient information.
- Healthcare professionals delivering a sexual health service should be familiar with the ethical and legal frameworks on safeguarding adults and children, consent and confidentiality.
- It is good practice to obtain consent to share information with general practitioners (GPs) or family doctors, where the diagnosis or procedure may have longer-term health implications.
- All attempts should be made to maintain patients’ dignity, allowing them to dress and undress in privacy, and only exposing areas as necessary to examine them.
- A chaperone should be offered for all intimate examinations, to reassure the patient, act as a witness and assist in the examination and performing of any investigation. This offer should be documented, along with the name of the chaperone, in the medical record. Consent for any other staff in training to be present in the consultation should be ideally sought before the patient enters the room, to ensure they do not feel under pressure to comply.
- History taking should be done systemically with more sensitive questions being left until later. Structured proformas can be used to document the key history and examination findings, and subsequent investigations and results.
- When taking a sexual history, the healthcare provider should modify their language to ensure it is comprehensible to the patient. This will often mean avoiding medical jargon and instead utilizing sexually explicit language with which both the patient and the clinician are comfortable.
- People presenting to sexual health clinics vary in the complexity of their presentation. Some present asymptomatically for routine STI testing and might be considered ‘low risk’ attendees.
- There are many sexual health services which now offer an online consultation/no‐talk’ service by self‐completed questionnaires and computer‐assisted structured interviews (CASI). Studies have shown that in many cases, reporting by CASI was more reliable, with more patients divulging potentially risky sexual behavior than when asked via face‐to‐face interviews.
- Some areas have also seen the introduction of the ‘eSexual health clinic’, which is an online clinical and public health intervention. Patients with chlamydia are diagnosed and managed via an automated online clinical consultation, leading to antibiotic collection from a pharmacy. This could be an innovative model to address the growing population of sexual health needs but it is not a suitable method for vulnerable groups or those where there may be communication difficulties. (2D)
During history taking, it is important to ask the following in female patients:
- ‐ Lower genital tract symptoms:
- Vaginal discharge that has changed in quantity, texture, color or smell
- Vulval symptoms such as pruritus, lumps, ulceration and superficial dyspareunia.
- ‐ Upper genital tract symptoms:
- Pelvic pain
- Deep dyspareunia
- Menstrual cycle abnormalities:
- □ Intermenstrual bleeding
- □ Postcoital bleeding
- □ Menorrhagia
- □ Dysmenorrhoea.
For male patients, the following symptoms should be enquired about:
- ‐ Genital lumps
- ‐ Genital Ulceration
- ‐ Urethral discharge
- ‐ Testicular symptoms:
- ‐ Lower urinary tract symptoms:
- ‐ Genital itching, soreness or rashes.
In both male and female patients, ask about:
- ‐ Rectal symptoms (when relevant to the sexual history):
- Rectal discharge
- Rectal bleeding
- Rectal pain
- Anorectal skin changes
- ‐ Oral Lesions
- ‐ Conjunctivitis
- ‐ Rashes – genital and/or disseminated
- ‐ Mono/pauciarticular arthritis
- ‐ Systemic symptoms of weight loss, malaise, night sweats, skin lesions, lymphadenopathy.
- ‐ Sexual difficulties or dissatisfaction with sexual life should be specifically asked as these may not be volunteered. Where these are identified, appropriate referral pathways should be followed.
Following on from the symptoms, it is important to ask about the patient's general health, sexual history, and social history.
- ‐ Past medical history
- ‐ Past surgical history
- ‐ Past history of STI testing, including HIV (which may include blood donation or antenatal screening) and any positive results
- ‐ A thorough medication history (including over the counter and herbal remedies)
- ‐ Drug allergies
- ‐ In females, a gynecological and obstetric history, to include cervical cytology, including abnormal results requiring treatment, and contraceptive history which may identify women who require emergency contraception
- ‐ History of vaccinations relevant to sexual health
- Hepatitis A
- Hepatitis B
- Human papillomavirus (HPV)
- ‐ Family history may be relevant for consultations involving contraception choices or in cases where congenital infection may be suspected
- ‐ Sexual history
- Date of last sexual contact
- Gender of sexual partner
- Anatomical sites of exposure
- Condom use including any condom accidents
- Any suspected infection or symptoms in partner
- Previous sexual contacts in the last 3 months, or if the patient is known or suspected having a particular STI, the look-back period for that particular infection should be used (refer to specific guidelines for more details)
- The practice of ‘Swinging’ – heterosexual men and women who as a couple have sex with others. This group represents a high‐risk population as they commonly report bisexual behavior with multiple concurrent partners. Unless questions are specifically asked, they are likely to be an under-recognized group. Such questions may include ‘are you a swinger’, ‘do you practice partner‐swapping’, ‘do you have sex with other couples together with your partner’ and ‘do you visit sex clubs for couples.
- ‐ Enquiring about alcohol and recreational drug use may be relevant in terms of risk‐taking behaviour. More recently, the phenomenon of ‘Chemsex’ (use of recreational drugs to facilitate and heighten sexual experiences) has been identified as a public and sexual health problem. The most commonly used drugs are crystal methamphetamine, gamma‐hydroxybutyrate (GHB), gamma‐butyrolactone (GBL) and mephedrone. Chemsex is associated with risky sexual behavior and increased risk of STIs including HIV, hence the importance within a sexual health consultation.
Onward referral to appropriate services that can support chemsex users towards abstinence or risk reduction strategies should be considered. (2D)
- ‐ Previous and current HIV PEP (postexposure prophylaxis) and PrEP (pre-exposure prophylaxis) use if these are available in your practicing country. The provision of PEPSE should be fully integrated into a course of advice and counseling around safer sex strategies. (2D)
- ‐ Gender‐based violence (GBV)/intimate partner violence (IPV)/domestic violence should be enquired about as they can be associated with sexual assault, STIs and unintended pregnancy.
An assessment of blood‐borne virus (BBV) risk will identify characteristics associated with high risk of HIV, hepatitis B and hepatitis C acquisition
- Men who have sex with men (MSM) and other bisexual men and transwomen
- Commercial sex workers
- Intravenous drug user
- People who have sexual partners from areas of high HIV prevalence rates, e.g. sub‐Saharan Africa
- History of blood transfusions, non‐professional tattoos or piercings
- Sexual partners of the above
Specific factors to consider in the trans‐population
- Transgender people may have any combination of sexual partners who are cis‐ or transmen or women.
- Transmen, who have not undergone gender reassignment surgery (GRS) and who have sex with cis‐men, may be at risk of unintended pregnancy.
- Transpeople need preventive health screenings as recommended for the body parts the patient has, regardless of that patient's gender identity. This will include breast, cervical and prostate cancer screening.
- Transpeople face high rates of social and economic marginalization as well as high rates of physical and sexual abuse.
Physical examination of the patient
- It is rarely necessary to examine the patient if there are no symptoms.
- In asymptomatic men, first void urine samples and asymptomatic women self‐taken vulvovaginal swabs for nucleic acid amplification testing (NAAT), provide sensitive and specific results for Chlamydia trachomatis and Neisseria gonorrhoeae and avoid the need for the intimate examination which may deter some patients from attending.27-29 In MSM, oropharyngeal and self‐taken rectal swabs are a viable and acceptable option. (1B)
However, patients presenting with symptoms suggestive of a possible STI should have a physical examination. The examination should include the following:
- Anogenital area
- Speculum examination in females
- Bimanual pelvic examination in females reporting upper genital tract symptoms
- Proctoscopy in males and females complaining of rectal symptoms
- Digital rectal examination where prostatic or rectal pathology is suspected
- Another general (i.e. non‐genital) examination as indicated by the history (2D)
Examination of a patient who has been a victim of sexual assault should occur after considering the need for forensic examination with an appropriate time frame for recovery of evidence. Not all clinics will need, or be able, to provide a forensic service, but a protocol for local referral must be available.
Staff should follow local processes for the taking, storage, and transportation of microbiological samples.
When ordering investigations for STIs, the window periods need to be taken into consideration. Knowledge of local laboratory assays is required to determine window periods for infections and therefore guide advice about the need for repeat testing.
All patients should be offered to test for
- Chlamydia trachomatis (NAAT)
- Neisseria gonorrhoeae (NAAT)
Other infections should be tested for based on history, examination findings and the local availability of tests.
- Candida albicans
- Bacterial vaginosis
- Trichomonas vaginalis
- Mycoplasma genitalium
- Herpes simplex virus (HSV)
- Lymphogranuloma venereum (LGV)
- Granuloma inguinale
- •Hepatitis B and hepatitis C
- Please refer to the 2017 IUSTI guidelines on hepatitis for more information https://iusti.org/regions/Europe/pdf/2017/IUSTIEuropeHepatitis2017.pdf
- •Urinary symptoms
- Urinalysis and midstream urine for culture and sensitivity
- •Pregnancy test
- Required when there is a risk of pregnancy, particularly when ectopic pregnancy falls within the differential diagnosis
- Point of care testing (POCT)
- These exist for various infections (including HIV, syphilis, and TV) and are useful in certain settings, particularly community or outreach environments.
- Light‐field microscopy of genital smears, or dark‐field microscopy of genital ulceration, can provide an immediate result to facilitate appropriate treatment at the time of consultation. The sensitivity of microscopy will vary according to the sampling technique and user experience.
- The sensitivity and specificity of all POCTs can vary, and they must be approved, so liaison with local laboratory services is advised.
- •Additional tests in MSM
- Rectal and pharyngeal NAAT tests (according to sexual history)
- Proctoscopy if symptomatic
- LGV testing if rectal chlamydia positive
The need for testing extra‐genital sites in women should be considered according to sexual history. Services may need to decide a local policy on screening asymptomatic women at pharyngeal and rectal sites pending further studies and data on cost‐effectiveness. (2C) Clinics should be familiar with the assays used locally and sensitivities may vary for extra‐genital sites, and not all are approved for extra‐genital testing.
Results and treatment
- At the end of the consultation, it is important to communicate with patients how and when they will receive their results.
- Diagnoses should be explained, with opportunities for questions, and appropriate patient information leaflets provided were available in several other European languages.
- In many cases, it is possible to give immediate results – microscopy, POCTs.
- Services need to ensure prompt availability of relevant treatments.
- Treatment may also be indicated on epidemiological grounds at the initial visit prior to results being available. For example, patients who present as the partner of a known STI may be treated at first presentation, in addition to being tested (please see guidelines on specific infections for further information).
- To maximize compliance, and hence successful treatment, single‐dose treatments administered in the clinic are preferred where possible. In addition, providing medications without charge is desirable as it removes barrier to treatment. (1C)
- Appropriate treatment should be prescribed to women or who are pregnant, breastfeeding or in whom pregnancy cannot be excluded.
- Information should be provided about the need to abstain from unprotected sexual intercourse to avoid onward transmission or re‐infection.
- Attendance at a sexual health clinic offers the opportunity to deliver health promotion advice, regardless of results.
- A brief behavior change such as motivational interviewing is no more time consuming and is more effective than simply giving advice. Motivational interviewing is a collaborative, person-centered form of guidance aimed at eliciting and strengthening an individual's motivation for change. This strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change.
- The reporting of confirmed STI diagnoses should be in line with local policy and will assist with epidemiological studies and planning of healthcare resources.
- The treatments of specific conditions can be found in other European guidelines and are not covered here.