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SHACC Algorithms

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New HIV diagnosis
General Sexual History Taking Initial Presentation / Roles History and examination - females History and examination - males
Sample handling Result handling Partner notification Sexual Assault

For new HIV diagnoses PHE have asked we complete the secure questionnaire here, which has replaced the old paper version (April 2015).

How is taking a sexual history for you?

  • When was the last time you took a sexual history?
  • Why did you take it?
  • Was it easy or did you find it difficult?
  • What was the setting? Is there a difference between a GUM clinic and a health centre?

Why take a sexual history?

  • What are we trying to find out?
  • How will this affect our management?
  • How is this different from normal history taking?
  • Taking the sexual history in different circumstances
    • Family planning clinic, gynae OPD, on the ward, in general practice, in GUM clinic

Objectives

  • identify why to take a sexual history
  • discuss situation when a sexual history may be appropriate
  • identify ways of changing the subject
  • identify the main components of a sexual history
  • practise taking a sexual history

How to start the conversation

  • Leaflets and posters
  • Routinely in certain situations/clinics
  • Women
    • smears
    • contraception
    • vaginal discharge & “thrush”
  • Men are more difficult
    • Symptoms
    • Clues from the client
    • “Do you have any other concerns?”

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Taking a sexual history

  • Ensure privacy
  • Be non-judgmental
  • Always explain why you are asking specific questions
  • Only ask relevant questions
  • Back off if interaction is poor
  • Give permission for the client to return to discuss
  • How do doctors make it difficult for patients?
    • Fail to take verbal/non verbal factors into account
    • Use of jargon, inappropriate language
    • Assume everyone is heterosexual
    • Difficulty in dealing with patient’s guilt, anger and fear

Communication

  • Good communication skills
    • Eye contact
    • Meet and greet
    • Introductions
    • Body language
    • Vocabulary
    • Open then closed questions
    • Awareness of distress, non verbal clues
  • Problems with communication
    • Deaf
    • Inability to speak English
    • Use of interpreters
    • Family members as interpreters?
    • Language line

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Initial Presentation

  • Patient asks receptionist for sexual health screening or is referred by single point of access
  • Ask “Have you noticed anything wrong?”
  • And “Has a partner said you need to get checked?”
  • Occasionally they might say “I have been sexually assaulted”
  • If any of above affirmed then book with experienced Nurse/Doctor
  • If all negative then book with Healthcare Assistant (HCA)/Nurse
  • Obtain patient details
    • Name, dob, sex, mobile number, GP, special language needs, etc

HCA & the asymptomatic patient

  • Register patient details on computer
  • If sex within 1wk, test and repeat in 2wks
  • Offer chlamydia test
    • First catch urine for men
    • Self administered vaginal swab for women
    • Or urine test if they prefer
  • Offer test for HIV/Syphilis (oral/prick/blood)
  • Explain arrangements for results
  • Opportunistic health promotion/condoms

Role of Nurse / Doctor

  • If HCA finds out there are symptoms refer on
  • Nurse works to his/her level of expertise…
  • …Refers to GP who works to his/her level of expertise…
  • …Refers to Dr Cross/Wake for second opinion
  • Can be done by phone or email
  • GUM Clinic as tertiary referral centre

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What does the Health Care Professional (HCP) need to know?

  • What symptoms do you have?
  • Exposure history
  • Use of contraception/risk of pregnancy
  • Other sexual health issues (psychosexual problems)
  • Risk of blood borne viral infections
  • Risky behaviours

Presenting complaint

  • Usually vague “I want to be tested”
  • Important to find out why, be curious
  • Specific symptoms in women
    • Discharge, pain, dysuria, bleeding, rash
  • Specific symptoms in men
    • Discharge, dysuria, rash, anal symptoms

Specific questions

  • When did you last have sex?
  • Who with?
    • Regular partner, casual contact
    • Do they have symptoms?
  • Previous partners in last X months?
  • What did you do?
  • Did you use condoms? How effectively?
  • Previous sexually transmitted infections
  • Past medical history
  • Medication, history of allergies
  • Contraception, LMP
  • Last cervical smear
  • Intravenous Drug Use
  • Partner from overseas?
  • Tattooing, dental care, blood transfusions, operations overseas
  • Paid for sex
  • Previous STI and HIV testing
  • Previous Hepatitis B vaccination

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Sexual History – Women

  • Symptoms
    • Vaginal discharge
    • Vulval itching
    • Abnormal bleeding
    • Pain during sex
    • Pain passing urine
    • Skin rash, lumps, ulcers
  • “Is there a chance you could be pregnant?”
  • “Do you also need contraceptive advice?”
  • “Have you been sexually assaulted?”
  • “Have you ever had a sexually transmitted disease?”
  • “When did you last have unprotected sex?”

Examination – Women

  • Examine external genitalia
    • Warts
    • Ulcers
    • Lymphadenopathy
  • Speculum examination
    • Take high vaginal swab if discharge (candidiasis, trichomonas or bacterial vaginosis) suspected
    • Swab cervix for gonorrhoea (Stuart’s)
    • Swab endocervix for chlamydia

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Sexual History – Men

  • Symptoms
    • Discharge
    • Irritation inside penis
    • Discomfort passing urine
    • Skin rash, lumps, ulcers
  • “Do you have sex with men?”
  • “Have you ever had a sexually transmitted disease?”
  • “When did you last have unprotected sex?”

Examination – Men

  • Examine external genitalia
    • Warts
    • Ulcers
    • Lymphadenopathy
    • Urethral discharge
    • Balanitis/Posthitis
    • Scrotal contents
  • Take swab from urethral meatus (Stuart’s) to test for gonorrhoea
  • Take swabs from any genital ulcers (Viral Culture Media) to test for herpes
  • Ask man to provide first catch urine to test for chlamydia
  • Offer to test for blood borne viral infections
  • Arrangements for results

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Doing the tests

  • Keep viral culture media in the freezer before use, put back in fridge after use
  • Endocervical swabs
  • Urethral swabs
    • Men
    • Women
  • Chlamydia – ligase (PCR) DNA tests on urine becoming more available

Storing Samples

  • The following will keep over the weekend if kept refrigerated:
    • Viral transport media
    • Clotted blood for HIV & syphilis
    • SDA urine/swabs for chlamydia (48 hours)
  • Stuart’s media will keep gonorrhoea alive for 24 hours (best out of fridge)

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Results

  • If no mobile or text message not acceptable, make alternative arrangements (letter, email or appointment)
  • Patients with positive test results will receive a text message asking them to contact surgery where testing carried out
  • Patients with negative test results will not receive a text message, but could telephone surgery for results in 2 weeks
  • Patients with infection need a consultation
    • Discuss infection, natural history of disease
    • Partner notification
    • Receive treatment or referral
    • Do they need a test of cure?

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Partner Notification

  • Contact tracing
    • Traditionally done by health advisers in GUM
    • Recent research shows practice nurses in GP are just as good
    • Depends on quality of information from patient
    • At least get commitment from patient to tell partners to have STI screening
    • Sometimes it isn’t possible as casual partners are often untraceable
  • If patient is reluctant to tell partners to get checked, consider “You have been named...” letter which can be posted to them
  • Should be attempted for partners of patients with TV, gonorrhoea, chlamydia, NSU and HIV

Partner Notification – How far back?

  • Chlamydia & NSU
    • Symptomatic – 1 month from symptoms
    • Asymptomatic – 6 months
  • Gonorrhoea
    • Symptomatic – 1 month from symptoms
    • Asymptomatic – 3 months
  • HIV
    • Let the GUM clinic sort this out

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Rape/Sexual Assault

  • Ask patient if they want to report to the police
  • Juniper Lodge/Solace team can arrange for samples to be taken by experienced forensic MO
  • DNA evidence upto 7 days – don’t wash
  • If patient refuses to contact police, don’t forget emergency contraception, consider blood borne virus prophylaxis
  • Offer to perform STI screening one week and three months afterwards

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Last modified: 03-04-15