As figures released during Sexual Health Awareness Week show, STIs are on the increase and rates of new HIV infections are staying stubbornly high. Ailbhe Jordan assesses the current Irish policy direction
Last month’s launch of the RCPI’s annual Sexual Health Awareness Week (SHAW) brought a welcome focus back to issues of education and prevention in STIs, HIV and AIDS transmission.
During the week, the College presented its Better Sexual Health for Ireland Policy Statement. A detailed document which calls for a national sexual health programme focused around education, prevention and delivery of sexual health services, the statement recommends a number of ways in which this can be achieved.
The policy is timely, as recent years have shown a worrying rise in levels of some STIs. Rates of chlamydia, the most commonly reported STI in Ireland, doubled between 2006, when 3,144 cases were reported, and 2008 when the HPSC was notified of 6,290 new cases. Just over 1,000 new cases of gonorrhoea were notified between 2001 and 2004, however between 2005 and 2008 that number rose to more than 1,600. Syphilis too is on the increase, particularly in the MSM community.
Rates of HIV transmission, while decreasing annually, have remained stubbornly high. There were 320 people newly-diagnosed with HIV last year, just 10 less than in 2010, when 330 new diagnoses were reported.
The figures indicate an increase of sexual transmission of HIV which, Prof Sam McConkey, Policy Group member and Head of the Department of Infectious Diseases at Beaumont Hospital believes, is cause for concern as it indicates a retrograde slide in awareness and knowledge about safe sex.
“There are still a similar number of cases being diagnosed as there were five or 10 years ago, but there’s more sexual transmission, both in MSMs and heterosexuals,” he told the Medical Independent (MI).
“That data shows very clearly, firstly, that our national prevention programme for sexual transmission of HIV has grossly failed. Unfortunately, about half the people who were diagnosed with HIV in 2011 had advanced HIV. That tells us that those people probably had HIV on average eight to 10 years before they were diagnosed. There is a big pool of people out there that have not yet been diagnosed.”
And while rates of other STIs such as herpes and genital warts have fallen, clinicians are fearful that the Government has taken its eye off the ball in this area.
The Department of Health’s long awaited National Sexual Health Strategy, which was first mooted in 2007, has yet to be published. A spokesperson for the Department told MI that a steering group has been set up to oversee the drafting of this strategy, which will be submitted to Government when completed, but could not give a timeframe.
Commenting on what the strategy will recommend, the spokesperson said it will “formulate a strategic direction for the delivery of sexual health services”.
“The plan will focus on improving sexual health and wellbeing and address the surveillance, testing, treatment and prevention of HIV and STIs, crisis pregnancy, and sexual health education and promotion,” he added.
Speaking to this publication during SHAW, Co-Chair of the RCPI Policy Group on Sexual Health Prof Colin Bergin said he is concerned about the increase in numbers of new STIs each year. He feels the importance of developing a cohesive sexual health programme warrants the appointment of a national sexual health lead to administer it, in a manner similar to the HSE’s National Clinical Care Programmes.
“I think we need to transition from the policy statement through to a national strategy, through to a programme that would be accountable for the delivery of what the policy statement and the national strategy outlined,” he told MI.
“The only way you’re going to do that is along the lines of what has been done in every other clinical care programme that has been developed in the last two to three years. I think we need a national lead who is actively involved in the area of clinical service delivery and who will have the acumen, the interpersonal capacity and the specialty interest to see the key performance issues transition to a programme.”
Education
A key strand of the proposed programme centres on improving education and training for undergraduates and professionals involved in sexual health services, as well as establishing “a robust system for ongoing professional development”.
“I think there is an educational role that the medical profession can deliver on, and then there is also a professional role that the medical profession needs to deliver on,” Prof Bergin said.
“I’d say there’s a role for every medic in their interface with their general patient groups pertaining to education and to acknowledging that sexual health is part of normal life. It’s part of health and the questions that we ask around people’s alcohol and cigarette intake, substance misuse patterns and lifestyle should extend to sexual health practices. That should be seen as routine so that it doesn’t become triggered by certain events or certain perceptions.”
The statement places a strong emphasis on doctors working in primary care and at the front line in acute hospital care, where evidence suggests there is much scope for improving patient education, prevention, testing and detection of HIV and other STIs.
Studies have suggested that a third of HIV-positive patients do not enter healthcare until late in their infection, and a recent survey, carried out under Prof McConkey’s supervision, of 100 people who were newly-diagnosed with HIV, found that two-thirds had been in contact with the Irish healthcare system in the previous two years.
“Mostly it was through primary care or emergency departments,” he said.
“When we asked them the reason why they were going to the doctor, it was for things like weight loss, diarrhoea, fatigue and skin conditions that, in retrospect, we could say were probably HIV showing up early. But the opportunity for diagnosis had been missed.”
The RCPI’s Chlamydia Screening in Ireland Study, which was also unveiled at the SHAW launch, found that “the main barrier reported by young people to seeking or accepting an STI test was the stigma associated with chlamydia and other STIs. This stigma was greatest among women, especially those from rural backgrounds and in urban working class areas who feared the consequences of being publicly exposed – to their families and peers –through asking for an STI test”.
Interestingly, however, in spite of the perceived stigma associated with requesting an STI test, the survey found there was “a high level of willingness among young men and women to take a chlamydia test if offered by a health professional”.
In total, 95 per cent said it would be acceptable to be offered the test and 75 per cent of students said they would accept the test if offered.
There is a consensus among infectious disease experts that normalising STI testing and offering it as part of a routine GP check-up is highly effective, and it would seem that it is acceptable to most patients, so why isn’t it happening?
“It’s always going to be difficult for a general practitioner to get significantly involved in managing sexually transmitted infections simply because patients know their GP in Ireland, they’ve often been at the same GP from when they were young,” according to Dr Colm O’Mahony, who diagnosed the first AIDS case in Ireland and is now a consultant physician in sexual health and HIV with the Countess of Chester NHS Trust.
“It’s very embarrassing to actually go to an old friend like that and say ‘Look, I was out with the lads and got drunk and one thing led to another and I had unprotected sex with somebody, I didn’t even know who they were, I’m really embarrassed and I need a full check up’. In many cases even the GP would be embarrassed. So I have great sympathy for general practitioners not so much in their reticence to deal with it, but in their genuine ability.”
“Even for the young keen GPs who have been highly trained, if somebody comes in with a maculopapular rash that looks like it could be measles, an allergic reaction or anything, it could also be syphilis. And if they say to the patient I want to check you for various things including syphilis, the patient might be quite offended by the GP’s intimation that maybe they’ve been out having indiscriminate sex. So, it will always be difficult for GPs.”
Sexual history
Dr Dominic Rowley, who is a GP and SpR at the GUIDE Clinic in St James’s Hospital, thinks that sexual history taking needs to become part of routine consultations at both primary care and frontline hospital level and should never be based on any perception of risk.
“We’re very bad at making assumptions about peoples’ sex lives; we think people look straight, we think people look gay, we define them by how they look. We shouldn’t define people. We need to ask them,” he told MI.
Education around spotting red flags and less obvious potential symptoms is also key to making this programme a success, Prof McConkey believes.
“It should be part of our dementia screen and it should be part of our fatigue screen. If people have ever had sex once without a condom, then we should be saying it’s a possibility, we should be doing a HIV test. I hope that over the next year or two we do end up with GPs getting more empowered and more comfortable talking about sexual health, to bring up these issues and to do some pre-test counselling and a HIV test, both in primary care and also in EDs.”
Education around consent is also needed, with evidence of a perception amongst some GPs and NCHDs that written consent from a patient is still required to carry out a HIV test, when in fact, under the US Center of Disease Control (CDC) 2006 guidelines, written consent is no longer required.
“The CDC says implied consent is sufficient, so if you are getting a blood test for any other reason, you can get a HIV test done as simply as getting Hb levels checked. Obviously this is a little bit controversial, but you can stand over it. Basically they are saying you now do not need separate consent,“ Dr Rowley told MI in a separate interview earlier this year.
Prof Bergin believes the pre-valence in some regions is high enough that clinicians should be empowered to carry out universal testing for HIV.
“From the urban data coming through on HIV prevalence and incidence rates, I think we are approaching a time when there would be a call for universal testing in the Dublin area, or certainly enhanced, targeted testing,” he said.
“So we have to find some way in which we destigmatise the issues. We’re very conscious that even in surveys of NCHDS in urban hospitals, there is still this perception around the requirement for written consent. There is a need to educate and reassure colleagues and trainees that HIV testing should be seen to be part of a routine health investigation.”
Dr O’Mahony believes encouragement at Government level for widespread STI testing in general practice in the UK had a key impact there.
“The only way we’re going to improve early diagnosis of HIV is by general practice doing more testing,” he said.
“In 2007, the [UK] Chief Medical Officer Sir Liam Donaldson, wrote to every doctor in the country basically saying ‘Look lads, we’re missing HIV all over the shop, it’s costing a fortune and there’s onward transmission, you really need to normalise HIV testing. Please get doing it far more than you are currently doing’. If patients are presenting with say anaemia or swollen glands, as well as checking for glandular fever and all that stuff, you should really be checking for HIV.”
The British Association for Sexual Health and HIV (BASHH) has also compiled a set of indicator conditions for HIV in each specialty that clinicians should watch out for (see Table 1).
Standards
The way in which sexual health training is provided for GPs in Ireland also needs to be standardised, Dr Rowley believes.
“The GUIDE clinic runs the STI Foundation (STIF) course twice a year. These are voluntary courses,” he explained.
“Sometimes GP schemes invite lecturers in. For example, I do a full day for the Trinity scheme every year, but it very much depends on which scheme you’re on. There’s no specific sexual health training programme. A lot of GP trainees just do the family planning certificate and that covers a bit of sexual work. The approach is a bit piecemeal.”
Dr Gerry Mansfield, National Director of Specialist Training with the ICGP and a Dun Laoghaire-based GP, established a formalised STI service following BASHH guidelines and standards in his practice in 2007. He believes that GPs have the basic knowledge to advise patients about STIs and have access to adequate training if they wish to develop a special interest.
“I think all GPs would know how to handle a person presenting with a query about a sexually transmitted infection, but that’s a different issue from looking after patients exclusively, doing all of their screening and all of their treatment. They are different things,” he said.
“I don’t think you could say that all GPs graduating from GP training are fully comfortable with, for example, doing STI screening, but then again you could say that about removing toenails or doing skin biopsies. People need to learn. The courses are provided, like the STIF courses provided around Dublin. It’s something we all did. I think if you say you’re going to provide a service like this you have to be up to date, you need to be skilled appropriately. We’re just incorporating it into a busy general practice. You come in for a cough or a cold and you think you might have a sore throat. It’s just the same thing if you come in and you think you might have an STI. That’s the mindset approach and I think if people can organise their practice management side of things, organise their consultations to make it time efficient, that’s always the big thing.”
He believes there is a willingness among GPs to get more involved in sexual healthcare, but cautions against the RCPI placing too much emphasis on extra training, when those resources could be used to support GPs in taking on the extra workload of STI testing.
“I think this is something that GPs do, and now the college seems to feel that we need to do a particular course and be reaccredited to do it. I don’t need to reaccredit myself to examine somebody‘s heart, or to do multiple other tasks,” Dr Mansfield said.
“When you can do this with-out it taking up an excessive amount of time, then it becomes normal. However, unfortunately, the way things are at the moment, it’s not within the GMS contract. I think the good thing is that there is a general enthusiasm to do these things. It’s a question of whether there is support, either through provision of resources for nurses or just recognising it as an STC form, a bit like when there we-re initiatives done for Implanon and Mirena coil insertions to address other women’s health issues. I think if GPs are doing something that is outside of the normal contract, they want a payment. General practice is still a private business; someone has to pay the rent.”
Primary care
Dr Fiona Lyons, Policy Group Lead on Prevention Services and Consultant Physician in Genitourinary Medicine at St James’s Hospital, acknowledges that there is, “a huge appetite for improving knowledge within primary care”.
“Every talk I ever give about anything related to sexual health, the turnout is enormous, so there’s definitely an appetite there,” she told MI.
“I organise the STIF course in St James’s Hospital and there is always a waiting list. We have been working with the ICGP and I think this week represents a beautiful opportunity to build on the momentum we have gained thus far. It’s hard to measure the deficits at the minute, but there is definitely a willingness and an appetite within primary care to engage in this process.”
Dr Bergin also acknowledges that GPs may require additional supports, but believes that the nature of STI detection and treatment should not entail an undue extra work burden for them.
“For the majority of people it’s a single event, it’s not a chronic disease. While the work burden might be there volume wise, it’s not there from a chronicity point of view,” he said.
“If adequately resourced, if the structure around the model is correct and the referral pathways are in place, the educational supports are in place, the contact tracing supports are in place, I would be very surprised if there was a reluctance from GPs to engage.”
Whether willing or not, Dr O’Mahony believes that front line clinicians are potentially putting themselves in the firing line by not getting to grips with early STI detection.
“In my opinion, the only thing that is going to get GPs and general hospital doctors doing routine HIV testing is when a couple of them have the living daylights sued out of them for not testing,” he said.
“This has already happened in America and Australia, and they really test for HIV there. In Australia everyone has been tested at least once. It’s almost routine because people are getting sued. For example, one GP was considered negligent for not doing a test on a chap who then went on to infect his girlfriend. It was considered that the GP had a duty of care to the girlfriend and by not testing the man earlier he was negligent in allowing her to become positive. You can see the logic of it.”
In addition there is the danger that for-profit entities could swoop in to fill any gaps in primary care STI services, as private healthcare providers such as Virgin Care have done in the NHS. “It is shameful and I hope it never happens in Ireland,” he said.
A recent deal on an Irish group deals website offering “comprehensive STI screening with GP consultation” at a 61 per cent discount on the normal cost, suggests that the commodification of STI services may have already begun.
There is also, of course, the impact of late diagnosis on patients, as well as the increased burden of care they represent and the associated economic implications.
“It’s a really significant problem even from a socio-economic point of view, as patients are much more ill when they arrive,” Dr Rowley explained.
“They will often come to us via an ICU transfer, certainly in emergency situations. We’ve had a number of admissions this year where the patient was in ICU and it’s discovered there that they are HIV positive and they are transferred over to us. Some of these patients would have been positive for 10 years, some for three years, depending on how quickly their disease progressed. You’re talking about a huge burden of care.”