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Dr Deborah Lee MFFP MRCGP DRCOG Dip GUM Associate Specialist in Reproductive Health,

Meeting Demand for Comprehensive Sexual Health Needs: the Experience within a Primary Care Setting in the UK. Dr Deborah Lee MFFP MRCGP DRCOG Dip GUM Associate Specialist in Reproductive Health, The Alma Clinic, Winton Health Centre, Bournemouth, UK. May 2006. Introduction.

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Dr Deborah Lee MFFP MRCGP DRCOG Dip GUM Associate Specialist in Reproductive Health,

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  1. Meeting Demand for Comprehensive Sexual Health Needs: the Experience within a Primary Care Setting in the UK. Dr Deborah Lee MFFP MRCGP DRCOG Dip GUM Associate Specialist in Reproductive Health, The Alma Clinic, Winton Health Centre, Bournemouth, UK. May 2006

  2. Introduction • We are in the midst of an STI crisis in the United Kingdom1 • Until recently, testing for Sexually Transmitted Infections (STI’s), and Contraceptive Services, have been provided at separate clinic sites. • The National Strategy for Sexual Health & HIV1 has highlighted the importance of comprehensive and integrated sexual health services. Aimed to pilot “One stop shops” To evaluate the role of GP’s and Primary Care Teams with a special interest in sexual health 1. Better prevention, better services, better sexual health - The national strategy for sexual health and HIV. Department of Health 2001

  3. Why a “One Stop” Service? • Both contraceptive and STI related sexual health needs, may be identified and addressed in one single consultation. • This may reduce long-term poor sexual health outcomes. • “One Stop” models of care have been endorsed by the Independent Advisory Group (IAG) on Sexual Health and HIV. 2 • Published outcomes of other combined sexual health clinics are highly relevant. 2. Response to Health Select Committee Report on Sexual Health & HIV. Independent Sexual Health Advisory Group on Sexual Health and HIV (IAG). January 2004.

  4. Setting • We took an established Family Planning Clinic (Winton Family Planning Clinic), • located within General Practice premises, • in Bournemouth, a large south coastal town, • and introduced the availability of full STI screening: The Alma Clinic.

  5. The Alma Clinic STI appointment • Confidentiality • Patients registered and have separate clinic notes • Appointment only/emergency access • Mondays, Tuesday evenings, Fridays, and first and last Saturday morning of the month • New patients 30 minutes, follow up 10 minutes • Follow recommendations for testing for STI in a Primary Care Setting (BASHH 2005)3 • Full sexual history taking & risk assessment • Standard clinic proforma • Patient satisfaction surveyed separately with a highly favourable outcome. 3. Sexually Transmitted Infections: Screening & Testing Guidelines draft 2005. British Association of Sexual Health & HIV (BASHH)

  6. The Alma Clinic STI screen • NAAT testing for chlamydia and gonorrhoea • One endocervical swab/first pass urine, tests for the presence of both infections • BD Tech probe kit: sensitivity endocervical swab for chlamydia/gonorrhoea is 97.6%, specificity 98-100% • If NAAT test positive for gonorrhoea, patient treated and referred to GUM for culture and sensitivity • We swab all separate sites of sexual contact • No microscopy • High Vaginal Swab (HVS) for bacterial vaginosis (BV), candida & trichomonas vaginalis (TV), pH paper • Laboratory Standard Operating Procedure: HVS: gram stained for microscopy, plus culture (Sabaraud’s medium) for candida, and specific culture for TV • Serology; hepatitis B & C, syphilis and HIV • Viral culture medium for herpes simplex (HSV)

  7. GUM services STI assessment, testing & treatment for males and females Positive STIs managed in line with BASHH recommendations Work in liaison with local GUM department Health Advisor: Contact tracing/contact slips Diagnosis and treatment of genital warts Cryotherapy/Podophyllotoxin home treatments eg Warticon Diagnose and treat Pelvic Inflammatory Disease Free condoms: Sexual health advice Hepatitis B imminusation Contraceptive services All currently available forms of contraception “LARC” methods IUD/IUS/Implants Emergency contraception Pregnancy testing & referral Counselling & referral for sterilisation (A vasectomy service operates in-house) Counselling & referral for unplanned pregnancy (including Early Medical Abortion (EMA) run by the local Family Planning Service) Cervical cytology The Alma Clinic: combined services offered “one stop” approach Sexual Health Strategy 2001: Level One, Two (& some Level Three) Services

  8. MethodAlma Clinic Survey • Alma Clinic attendances in first 6 months of operation 1/01 - 30/06/2005 • Numbers, age and sex of patients • Prospective data collection (STIs) • STI tests requested/Positive diagnoses • HIV testing • Hepatitis B immunisation • Percentage of women who attended for STI testing but needed contraceptive advice/help

  9. ResultsNumber of patients attending Alma Clinic Numbers of patients in past 6 months* attending the Alma Clinic * 1/07/05-31/12/05 (the 6 months after the study period)

  10. Age of Patients attending Alma Clinic for STI testing Alma Clinic 2005

  11. Positive STI diagnosesAlma Clinic 2005

  12. Alma Clinic Positive STI diagnoses • Overall incidence of positive STI diagnoses* in first 6 months of Alma Clinic was 29/98 (30%) • * This does not include BV/Candida, but does include genital warts and PID. • The incidence of chlamydia positives was 12/98 (12%)

  13. STI Clinic Attenders:Contraceptive ActivityAlma Clinic 2005

  14. STI Attenders:Alma Clinic Other Activity Alma Clinic 2005

  15. Conclusion • STI testing in a Primary Care/Family Planning clinic is practicable and achievable. • 30% patients tested positive for an STI. • 12% tested positive to chlamydia (higher than previously quoted GP prevalence). • 28% patients attending this clinic for STI testing, were given advice to choose/change contraception. With acknowledgement and thanks to the Alma Clinic Team, notably Dr Carol Linnard, Kerrie Ewer RGN & Dr Alison Vaughan.

  16. Case scenario Nadine, aged 23, came to Winton FP clinic requesting removal of copper IUD • Reason? Increasingly heavy painful periods over past 2 years, pelvic pain • IUD fitted post-natally, daughter now aged 2 • This had been an unplanned pregnancy • Offered STI testing • Registered her as an Alma Clinic Patient

  17. Outcome • Sexual history and risk assessment • Numerous casual partners in past 3/12, including attending an orgy in Berlin where had had sex with 4 partners in one night, one of whom was bisexual • Treated for PID • IUD was removed, given Depo provera • Chlamydia positive/contact slips given • Hepatitis B immunisation • Implanon

  18. With acknowledgement and thanks to the Alma Clinic Team,notably Dr Carol Linnard, Kerrie Ewer RGN & Dr Alison Vaughan

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