1. BASHH 2009 Asymptomatic Screening Audit in UK GUM Clinics
~ Case Notes Audit ~

2. BASHH 2009 Asymptomatic Screening Audit
Audit methods
Results (selected)
Limitations
Conclusions
Recommendations for practice change 

3. Recommendations audited against
BASHH Clinical Effectiveness Group: Sexually Transmitted Infections: UK National Screening and Testing Guidelines August 2006* *

4. Asymptomatic case definition
No symptoms offered on presentation (either on a triage form, or similar form, or on direct questioning by a healthcare worker)
New or re-book

5. Methods First 30 consecutive patients January to March 2009
Questionnaire designed by NAG, available at:
Electronically data submission using Feedback Server software and downloaded for analysis using Microsoft Access and Excel.
Data collated and aggregated by
Clinics: regional aggregates
Regions: national aggregate

6. Results …

7. Main messages
HIV, syphilis, chlamydia – good testing performance against BASHH first line recommended tests
Gonorrhoea: good testing performance only when culture plus NAATs included
Throat and rectal gonorrhoea screening common practice for MSM
Especially when sexual history documented

8. Contribution of cases, N= 4428
4428 cases from 157 clinics
(~60% of all GU Medicine clinics)
Regional contribution: 2-17%

9. Gender & sexual preference, N= 4428
Men: 2297 (52%, 43–59%)
Heterosexual: 2078 (47%, 37–56%)
MSM: 219 (5%, 2–8%)
Women: 2131 (48%, 41–57%)

10. Results: specific infection screening in asymptomatic groups
HIV & syphilis screening …

11. HIV screening in asymptomatic groups
“All patients attending the GUM clinic should be offered an HIV test, according to the National Strategy for Sexual Health and HIV ” Testing uptake standard 60%
Group
Done n (%, regional range)
MSM
n= 219
207 (94%, %)
Heterosexual men n=2078
1731 (83%, 70-96%)
Women
n=2131
1716 (81%, 66-98%)

12. HIV testing in women (n=2131)

13. HIV testing in MSM (n=219)

14. Syphilis screening* in asymptomatic groups
“Screening is recommended for all asymptomatic patients attending a UK GU clinic”
Group
Done n (%, regional range)
MSM
n= 219
212 (97%, %)
Heterosexual men
n=2078
1755 (84%, 70-96%)
Women
n=2131
1735 (81%, 69-98%)
*Any test for syphilis: EIA, TPPA, VDRL/RPR,TPHA

15. Chlamydia screening …

16. Done n (%, regional range)
Chlamydial screening
Group
CEG Test of choice
Done n (%, regional range)
MSM
n= 219
Urine NAAT or urethral NAAT
210 (96%, %)
Het men n=2078
1991 (96%, %)
Women n=2131
Cx NAAT, VV NAAT, or urine NAAT
1987 (93%, %)
Urethral NAAT: het men 347 (17%, 0-69%), MSM 37 (17%, 0-60%), women 120 (7%, 0-32%)
Women
n=2131
Urine NAAT
233 (11%, 0-37%)
VV NAAT
347 (16%, 0-40%)

17. Gonorrhoea screening …

18. Done n (%, regional range)
MSM, n= 219
CEG test of choice: culture for invasive sampling
Tests for gonorrhoea
Done n (%, regional range)
Urethral culture only
119 (54%, 9-100%)
Urethral culture or urine NAAT*
207 (94%, %)
* Recommended if urethral specimen not available

19. Done n (%, regional range)
Heterosexual men, n=2078
CEG test of choice: culture for invasive sampling
Tests for gonorrhoea
Done n (%, regional range)
Urethral culture only
1194 (58%, 2-98%)
Urethral culture or urine NAAT*
1926 (93%, %)
* Recommended if urethral specimen not available

20. Done n (%, regional range)
Women, n=2131
CEG test of choice: culture for invasive sampling
Tests
Done n (%, regional range)
Cx culture
1393 (65%, 26-94%)
+ Cx NAAT, VV NAAT
1770 (83%, 53-99%)
+ Urine NAAT, urth NAAT, urth cult
1981 (93%, %)

21. Throat and rectal screening for gonorrhoea by culture

22. Asymptomatic MSM: rectal and throat gonorrhoea culture, n= 219
Site of test for gonorrhoea
CEG Recommends
Done n (%, regional range)
Rectum
100%, if indicated by sexual history
153 (70%)
Receptive anal sex documented n=141
119 (84%, %)
Receptive anal sex not documented n= 78
34 (44%, 0-100%)
Throat
175 (80%)
Receptive oral sex documented n=156
134 (86%, %)
Receptive oral sex not documented n= 63
41 (65%, 0-100%)

23. NAATs for gonorrhoea screening
Group
Urine
Done n (%, regional range)
Urethra
Cervical
Rectal
Throat
Het men
n=2078
751
(36%, 0-100%) 84
(4%, 0-16%) -
MSM n=219 98
(45%, 0-100%) 37
(17%, 0-60%) 33
(15%, 0-44%) 20
9%, 0-30%)
Women
n=2131
209
(10%, 0-36%)
(2%, 0-13%)
250
(12%, 0-44%) 5
(0.2%,0- 1.1%)
(0.2%, 0-2.3%)

24. Urine NAATs for Gc in MSM

25. Conclusions and recommendations

26. Limitations- not known:
Patient, clinician or systems preferences influencing choice of
Invasive/non-invasive sampling
NAATs/culture
Positive NAATs for gonorrhoea
Culture confirmation
Repeat testing with different NAAT target to avoid false positives

27. Main messages
HIV, syphilis, chlamydia – good testing performance against BASHH first line recommended tests
Gonorrhoea: good testing performance only when NAATs included
Urine GC NAATs: often used, including 45% MSM
Throat and rectal gonorrhoea screening common practice for MSM
Especially when sexual history documented

28. Suggested Areas for Practice Improvement/Interventions- 1
Increased documentation of discussion about oral and anal sex
Recommended in the BASHH Guideline on sexual history taking
Identifies anatomical sites for sampling

29. Suggested Areas for Practice Improvement/Interventions- 2
Culture needed in every clinic?
Regional strategies? …
… balance NAATs with culture testing for gonorrhoea to monitor antibiotic sensitivity
(Gonococcal Resistance to Antimicrobials Surveillance Programme)

30. Detailed data and PowerPoint presentation on: www. bashh
Detailed data and PowerPoint presentation on:
Late 2010: DH-funded audit of BASHH STI Management Standards
… the end

31. ACKNOWLEDGEMENTS
The work done by all NHS staff who submitted data and supported the Audit is gratefully acknowledged. The work done by those running the pre-pilot and pilot phases is gratefully acknowledged.
The work done by the Regional Chairs and staff in NHS Trusts/Clinics is gratefully acknowledged.
Membership of National Audit Group, October 2008: Chris Carne (Chair), David Daniels (Vice-Chair), Hugo McClean (Hon Sec), Anatole Menon-Johansson (Director of Development), Raymond Maw (N.Ireland and BCCG chair), Ed Wilkins/Alison Rodger (BHIVA Representative), TC Harry (Anglia), Gail Crowe (Essex), Ravindra Gokhale (Merseyside), Ann Sullivan (N Thames), Eva Jungmann (N Thames), Sarup Tayal (Northern), Ashish Sukthankar (North-West), Adil Isaac (Oxford), Steve Baguley (Scotland), Arnold Fernandes (South-West), Cindy Sethi (SE Thames), Steven Estreich (SW Thames), Jyoti Dhar (Trent), Helen Bailey (Wales), Sarah McAndrew (Wales), Reena Mani (Wessex), Kaveh Manavi (West Midlands), Amy Tobin-Mammen (Yorkshire), Paul Bunting (Co-opted Member), Irene Vaughan (Co-opted Member), Mike Walzman (Co-opted Member),Nicola Low (Co-opted Member).
The advice and support of Hilary Curtis in designing the on-line questionnaires and in collecting, processing and tabulating the audit data into a national aggregate and regional aggregates is gratefully acknowledged.