1. BASHH 09 Asymptomatic Screening Audit Case Notes Audit

2. Recommendations audited against Sexually Transmitted Infections: UK National Screening and Testing Guidelines August 2006 http://www.bashh.org/guidelines Recommended Tests for Asymptomatic Patients

3. Case definition No symptoms offered on presentation (either on a triage form, or similar form, or on direct questioning by a healthcare worker) Seen during a first meeting in a new or re-book episode

4. Methods First 30 consecutive patients seen during 1 January 2009 to 31 March 2009 Questionnaire designed by NAG, available at: http://www.bashh.org/groups Data electronically submitted May to July 2009 using Feedback Server software and downloaded for analysis using Microsoft Access and Excel. Pseudonymised data only collected Data collated and aggregated by Region, and by NHS Trusts/Clinics within Regions

5. Results – contribution of cases, N= 4428 4428 cases from 157 clinics (~60% of all GU Medicine clinics) Regional contribution: 2-17% London regions: 32% of cases New cases: 3296 (74%, regional range 58-94%) Rebook cases: 1132 (26%, 6-42%)

6. Results – gender & sexual preference, N= 4428 Men: 2297 (52%, 43–59%) –Heterosexual: 2078 (47%, 37–56%) –MSM: 219 (5%, 2–7.5%) Women: 2131 (48%, 41–57%) –Pregnant: 14 (0.3%, 0–1.3%)

7. Results – age distribution, N= 4428 Age groupNumber%, Regional range% <16401%, 0–3% 16–1847611%, 6–18% 19–24175640%, 32–46% 25–34143332%, 21–42% 35–44478 11%, 6–16% 45–541774%, 2–7% 55–64601%, 0.3–3% ≥6580.2%, 0–1%

8. Results – ethnic group, N= 4428 Ethnic groupNumber%, Regional range% White368583%, 65–97% Not known1894%, 0–30% Black African1313%, 0–7% Other1303%, 0–7% Black Caribbean1082%, 0–8% Indian521%, 0–4% Black Other481%, 0–3% Chinese/South-East Asian300.7%, 0–2% Pakistani220.5%, 0–2% Arabic130.3%, 0–1% Hispanic110.2%, 0–0.7% Bangladeshi90.2%, 0–1%

9. Asymptomatic heterosexual men n=2078 TestCEG Recommends Done n (%, regional range) Chlamydia (Urine NAAT or urethral NAAT) Yes1991 (96%, 81-100%) Gonorrhoea (Urethral culture* or urine NAAT**) Yes1926 (93%, 76-100%) Syphilis (Any test: EIA, TPPA, cardiolipin test,TPHA) Yes1755 (84%, 70-96%) HIVYes1731 (83%, 70-96%) Hep B (CAb, SAg or SAb) (n=2040, 38 known immune) No, unless in risk group 476 (23%, 7-60%) Urethral microscopyNo459 (22%, 0-87%) *Urethral culture only for gonorrhoea: 1194 (58%, 2-98%) **Recommended if urethral specimen not available

10. Asymptomatic MSM, n= 219 Test CEG Recommends Done n (%, regional range) Chlamydia (Urine NAAT or urethral NAAT) Yes210 (96%, 50-100%) Gonorrhoea (Urethral culture* or urine NAAT**) Yes207 (94%, 80-100%) Syphilis (Any test: EIA, TPPA, cardiolipin test,TPHA) Yes212 (97%, 90-100%) HIVYes207 (94%, 90-100%) Hep B (CAb, SAg or SAb) (n=154, 65 known immune) Yes127 (82%, 54-100%) Urethral microscopyNo38 (17%, 0-100%) *Urethral culture only for gonorrhoea: 119 (54%, 9-100%) **Recommended if urethral specimen not available

11. Asymptomatic MSM: rectal and throat gonorrhoea culture TestCEG Recommends Done n (%, regional range) Gonorrhoea, rectumYes, if indicated by sexual hx. Receptive anal sex documented n=141119 (84%, 67-100%) Receptive anal sex NOT documented n=7834 (44%, 0-100%) Gonorrhoea, throatYes, if indicated by sexual hx. Receptive oral sex documented n=156134 (86%, 75-100%) Receptive oral sex NOT documented n=6341 (65%, 0-100%)

12. Asymptomatic women n=2131 Test CEG Recommends Done n (%, regional range) Chlamydia (Cx, v/vagina, urethra or urine* NAAT) Yes1996 (93%, 73-100%) Gonorrhoea (Cervical culture) Yes1393 (65%, 26-94%) Syphilis (Any test: EIA, TPPA, cardiolipin test,TPHA) Yes1735 (81%, 69-98%) HIVYes1716 (81%, 66-98%) Hep B (CAb, SAg or SAb) (n=2103, 28 known immune) No, unless in risk group 475 (23%, 8-59%) Cervical microscopyNo248 (12%, 0-42%) * recommended if urethral specimen not available Chlamydia: any of cx NAAT, vv NAAT, urine NAAT, ur NAAT, ur cult, cx cult,vv cult: 2082 (98%, 94-100%) Gonorrhoea: any of cx culture, cx NAAT, vv NAAT: 1770 (83%, 53-99%) Gonorrhoea: any of cx NAAT, cx cult, vv NAAT, urine NAAT, ur NAAT and ur cult: 1981 (93%, 83-100%)

13. Asymptomatic women: rectal and throat gonorrhoea culture TestCEG RecommendsDone n (%, regional range) Gonorrhoea, rectumYes, if indicated by sexual hx. Receptive anal sex documented n=93 11 (12%,0-100%) Receptive anal sex NOT documented n=203827 (1%, 0-13%) Gonorrhoea, throatYes, if indicated by sexual hx. Receptive oral sex documented n=54965 (12%, 0-30%) Receptive oral sex NOT documented n=158215 (1%, 0-6%)

14. NAAT testing for gonorrhoea GroupUrine Done n (%, regional range) Cervical Done n (%, regional range) Rectal Done n (%, regional range) Het men n=2078 751 (36%, 0- 100%) N/A MSM n=219 98 (45%, 0- 100%) N/A Anal sex doc: 23/141 (16%, 0-67%) Anal sex not doc: 10/78 (13%, 0-50%) Women n=2131 209 (10%, 0- 36%) 250 (12%, 0-44%) Anal sex doc 4/93 (4%, 0-25%) Anal sex not doc 1/2038 (0.05%, 0-1%)

15. HIV testing* overall N=4428 *EIA, point of care or oral fluid tests (n=3) Nationally, any HIV test done: 248 of 287 (86%, 0-100%)

16. HIV testing in Black Ethnic Groups (n=287)

17. HIV testing in heterosexual men (n=2078)

18. HIV testing in MSM (n=219)

19. HIV testing in women (n=2131)

20. Hepatitis C antibody testing 566 of 4420 cases (13%, 4-57%) tested (8 known to have hep C antibody) MSM: 89 of 219 MSM (41%, 0-100%) tested (none known to have hep C antibody)

21. Conclusions High overall rates of testing with BASHH CEG first line recommended tests for chlamydia, syphilis and HIV High overall rates of testing for gonorrhoea in women when NAATs included Important number of cases having N. gonorrhoeae NAATs, including urine GC NAATs (45% MSM) Urethral microscopy ~ 20% men Cervical microscopy ~ 10% Most MSM tested for HepB (80%) Predominance of hepatitis C testing in MSM

22. Suggested Areas for Practice Improvement/Interventions Increased documentation of discussion about oral and anal sex, as recommended in the BASHH recommendations on sexual history taking to identify which anatomical sites need to be sampled for infection Regional strategies should be considered to balance nucleic acid amplification testing for gonorrhoea with culture testing to monitor antibiotic sensitivity Increased screening for hepatitis B in MSM is needed in some regions. Increased screening for HIV is needed in some regions, particularly for women

23. 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 (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.