London Genitourinary Medicine Clinic Research Articles

Observed Treatment Responses to Short-Course Doxycycline Therapy for Rectal Lymphogranuloma Venereum in Men Who Have Sex With Men.

Lymphogranuloma venereum (LGV) has reestablished itself as an endemic sexually transmitted infection in the United Kingdom and elsewhere in Europe and North America over the last decade. Current guidelines suggest treatment with 21 days of doxycycline; however, the evidence base for LGV treatment including its duration is very limited. We conducted a retrospective review in 2 central London genitourinary medicine clinics of men who have sex with men (MSM) with LGV in whom less than 21 days of doxycycline was used initially. Sixty MSM were treated initially with less than 21 days of doxycycline, of whom 50 (83%) were prescribed a 7-day course. Fifty percent of patients were asymptomatic, with the rest having rectal or other symptoms. Fifty-nine (97%) of 60 had a negative test of cure for LGV at a median of 31 days (7-200 days). Reinfection as opposed to treatment failure was considered likely in the patient testing positive. A second test of cure at a median of 139 days later (37-638 days) was completed in 30 patients, of whom 28 (93%) were negative for LGV. Seven to 14 days of doxycycline is effective in most cases of LGV with negative TOCs in 59 of 60 patients. These data suggest that 7 days of doxycycline is effective in achieving cure of rectal LGV in most MSM. There is a case for a randomized controlled trial of LGV treatment including a 7-day regimen of doxycycline.

P170 Risk factors forMycoplasma genitaliuminfection in symptomatic males, females and men who have sex with men from three clinical settings in London: Abstract P170 Table 1

Background/introduction Mycoplasma genitalium (MG), a sexually transmitted infection (STI), is increasingly recognised as a cause of major reproductive health sequelae. Treatment has become increasingly difficult due to macrolide and fluoroquinolone antibiotic resistance. MG is not routinely tested for in most UK genitourinary medicine (GUM) clinics, and limited risk-factor data exist for infection in at-risk populations and in different anatomical sites. Aim(s)/objectives To determine risk factors for MG infection in symptomatic male and female patients accessing three London GUM clinics. Methods Patients aged ≥16 years, symptomatic of an STI (or Chlamydia, Gonorrhoea, Trichomonas vaginalis, or non-specific urethritis contact) were consented. Additional-to-routine samples provided were vulvovaginal swab (VVS) (females), first void urine (FVU) (men-who-have-sex-with-women (MSW), (men-who-have-sex-with-men (MSM)), pharyngeal and rectal swabs (MSM). Samples were tested using the FTD Urethritis Plus Test kit and positives confirmed by Polymerase Chain Reaction. Risk factors were analysed using univariate and multivariate logistic regression. Results MG was detected in: 10.7% (95% CI 7.9%–13.5%) patients; 7.9% (95% CI 4.86%–10.94%) VVS; 19.4% (95% CI 11.76%–27.04%) MSW urine; 1.6% (95% CI 0%–4.72%) MSM urine; 0% MSM pharynx; 8.1% (95% CI 1.31%–14.89%) MSM rectum. Discussion/conclusion MG positivity was highest in MSW compared to the other patient groups, with younger age being the only risk factor for infection, remaining after multivariate analysis. The presence of rectal MG despite a lack of urogenital infection in MSMs warrants further investigation with a larger cohort. Overall the results indicate high MG positivity across symptomatic male and female populations.

P172 Implementation of alcohol screening in patients attending a large walk-in sexual health service within london

Background UK national guidelines advocate a role for sexual health services to offer routine screening for high-risk alcohol consumption in patients. Screening for alcohol misuse and offering brief interventions in this setting has been shown to be acceptable to clinicians and patients. In August 2014 the Fast Alcohol Screening Test (FAST) was incorporated into the sexual history proforma in a London Genitourinary Medicine (GUM) clinic. Aim An audit was undertaken to assess the use of the FAST tool and management of patients with a positive FAST result. Methods A retrospective case-notes review of randomly selected patients attending the GUM clinic in October 2014 was performed. Information was collected on patient demographics, sexual history, sexually transmitted infections, completion of FAST tool and action dependent on outcome of risk assessment. Results 169 case notes were reviewed: 55% female and 45% male, mean age was 30 (range 17–74) years. The FAST tool was completed in 87% (147/169) of case notes. Of patients screened, 86% (127) identified as low risk, 10% (15) increasing and 4% (5) high risk (hazardous drinkers). Of hazardous drinkers, 90% (18) had a documented action for risk reduction; 56% (10) had verbal advice documented, 22% (4) accepted written advice, 22% (4) accepted referral to a sexual health advisor. Conclusion Clinician completion of the FAST tool within the sexual history proforma in a busy clinic was high, with some scope for improvement. Of the relatively low number of hazardous drinkers identified, most accepted only brief verbal advice in clinic.

Trichomonas vaginalis: an audit of clinical practice and the demography of infected patients at three London genitourinary medicine clinics

This audit aimed to review clinical standards for Trichomonas vaginalis against British Association of Sexual Health and HIV (BASHH) guidelines. Case notes for patients who had a positive microscopy or culture result were reviewed retrospectively. There was a 0.23% positivity rate for T. vaginalis (n = 84 cases); 96% were female with an average age of 33 years, with proportionally more patients seen in the African/Caribbean population, despite the number of cases being comparable between white (n = 36) and African/Caribbean (n = 34) groups. Seventy percent of patients had both microscopy- and culture-positive results for T. vaginalis. Contact tracing occurred in 87% of patients; 56% of these patients confirmed at least one contact had been treated in the last month. Overall, our data demonstrated a lower positivity rate than expected. Wet microscopy and liquid medium cultures were both important in identifying the infection, but more needs to be done to ensure partner notification has been documented and contacts have been treated.

Finding cases of Trichomonas vaginalis infection in England

We describe the use of a new molecular assay for Trichomonas vaginalis (TV), the Gen-Probe Aptima TV (ATV) in female attendees at community clinics, a genitourinary (GU) medicine clinic and a prison GU medicine service. Positivity rates at community clinics and GU medicine were 0/382 (0%) and 3/358 (0.8%, 95% confidence interval [CI] 0-1.7%), respectively. Positivity was significantly higher, 29/269 (10.8%, 95% CI 7.1-14.5%), odds ratio (OR) 14.3 (4.11 < OR < 59.55), in those tested at the prison. A questionnaire survey of English GU medicine clinics and data from the UK Health Protection Agency (HPA) for England both demonstrated the large variation in case rates by region and testing methods employed. Higher rates were seen in women, in prison GU medicine services and in London GU medicine clinics. The ATV assay is now CE-marked (Conformité Européenne) and so a larger prospective study of its potential application is warranted.

Seven days of doxycycline is an effective treatment for asymptomatic rectal Chlamydia trachomatis infection

There are no evidence-based guidelines for the specific management of rectal Chlamydia trachomatis (CT) infection. All men who have sex with men (MSM) diagnosed with asymptomatic rectal CT by nucleic acid amplification test (NAAT) at a large London genitourinary (GU) medicine clinic between September 2006 and September 2009 were offered oral doxycycline 100 mg twice daily for seven days and invited for a test of cure (TOC) by CT NAAT four weeks after treatment. A total of 487 asymptomatic rectal CT infections were diagnosed and analysis was restricted to 165 TOCs from men whose only treatment had been doxycycline for seven days. The median time post-treatment for TOC was 45 days (interquartile range [IQR], 34-88). Only two patients tested CT-positive at follow-up. One had taken doxycycline only for three days; the other attended for TOC 240 days after the completion of doxycycline treatment and at this time presented with new symptoms in the context of ongoing high sexual risk. Our findings show that doxycycline 100 mg twice daily for seven days is highly effective treatment for asymptomatic rectal CT infection, achieving clearance of CT in 98.8% (163/165; 95% CI 95.4-99.9%) of cases. We advocate doxycycline for seven days as first-line therapy for asymptomatic rectal CT.

O3-S1.02 Deciphering the code of Treponema pallidum in the UK: implications for treatment and prevention

BackgroundThe efficacy and convenience of single-dose oral azithromycin meant it became the preferred treatment for syphilis in many countries and a suitable alternative to penicillin in many more. However, two...

Factors associated with genitourinary medicine clinic attendance and sexually transmitted infection diagnosis among central and east European migrants in London

ObjectivesThere has been a large influx of central and east European (CEE) migrants to the UK following the expansion of the European Union. This paper examines factors associated with genitourinary...

Anogenital herpes simplex suppressive therapy: an audit of transfer of care to general practitioners

A central London genitourinary medicine clinic introduced a policy of transfer to general practitioners (GPs) the care of all patients on successful suppressive treatment of recurrent herpes simplex virus (HSV) infection. An audit showed the initiation of transfer of care to GPs was 65%.

Low use and awareness of long-acting reversible contraception in women attending a South London genitourinary medicine clinic

Sirs: Samuel et al. describe how long-acting reversible contraception (LARC) in the form of a Mirena coil was useful for a woman with HIV. It improved her heavy periods and also provided effective contraception. National Institute for Health and Clinical Excellence (NICE) guidelines recommend LARC be promoted among sexually active teenagers a group who may have difficulties with consistent use of condoms and oral contraceptives. In January 2009 we conducted a cross-sectional survey to look at usage and awareness of LARC among women attending a genitourinary medicine clinic in southwest London. During a one-week period 122 women who attended the clinic were approached of whom 120 (98%) consented to filling in the questionnaire. The mean age of responders was 22 years (range 13-35) and 49 (41%) were teenagers. Most participants (57%) were from ethnic minorities. Thewomen described their ethnicity as white -43% black -42% (black-Caribbean black-African and black other) Indian -4% Pakistani -2% Chinese -2% any other ethnic group -7%. Current usage of LARC (defined as ?Depo provera injection implant or coil?) among the responders was 10% (11/120). This comprised 6% intrauterine contraceptive device (IUCD) 3% Depo provera injection and 1% contraceptive implant. Only four (8%) of the 49 teenagers were using LARC as their contraceptive method: three had an IUCD and one had an implant. Of all the participants 21% (24/120) said they had used LARC in the past. However more than half the women (54% [65/120]) including 59% (29/49) of teenagers said that they had never received any information about LARC. Over half the teenagers (57% 28/49) said their reason for not using LARC was ?insufficient information/knowledge?. We found that current usage of LARC (8%) among the teenagers in our study was much lower than other methods of contraception such as condoms (44%) and the contraceptive pill (34%). Samuel et al. point out the benefit of LARC in preventing pregnancy while preserving fertility. We agree that LARC should be more widely promoted especially among vulnerable teenagers. (full-text)

Microscopy detection of rectal gonorrhoea in asymptomatic men

This audit aimed to determine the usefulness of microscopy to detect presumptive rectal gonorrhoea (GC) infection in asymptomatic men. We retrospectively audited more than 400 male patients attending a London genitourinary medicine clinic from January 2005 to March 2007 who tested rectal culture positive for Neisseria gonorrhoeae and compared this with the microscopy detection rate. In total, 123/423 (29%) of culture positive samples were microscopy positive. Of those that tested microscopy negative (300/423), 64 (21%) were symptomatic and 236 (79%) asymptomatic. In addition, a time and motion study examined 81 rectal slides over a two-week period to identify microscopy reading time required to make a presumptive diagnosis of GC. Three slides were positive, resulting in six hours and 45 minutes to detect one positive sample. Given the low sensitivity for rectal microscopy coupled with the length of time required to obtain a presumptive positive rectal GC result, we believe rectal microscopy is no longer a cost-effective tool screening for asymptomatic men, and this report supports the BASHH guideline that it is not recommended in the management of asymptomatic rectal infection.

Lymphogranuloma venereum presenting as genital ulceration and inguinal syndrome in men who have sex with men in London, UK

Objectives: To describe a series of lymphogranuloma venereum (LGV) cases presenting as inguinal syndrome and/or genital ulceration seen among men who have sex with men (MSM) in London, UK. Methods:...

Increased attendances of people of eastern European origin at sexual health services in London

Objective:To describe the service use of migrants from eight central and eastern European (CEE) countries at two central London genitourinary medicine (GUM) clinics before and after accession to the European...

Black and minority ethnic men who have sex with men: a London genitourinary medicine clinic experience

The aim was to examine sexual behaviour and rates of sexually transmitted infections (STIs) in black and minority ethnic (BME) men who have sex with men (MSM) attending a London genitourinary medicine clinic. A case-note review of BME MSM (n = 203) attending our service between 1 April 2005 and 31 March 2006 was carried out. BME MSM were those who self-identified as being of Black (Caribbean, African or Other), South Asian (Indian, Pakistani, Bangladeshi or Sri Lankan) and Chinese/South-East Asian (Malaysian, Thai, Filipino, Japanese) ethnicities. Consecutively attending self-identified white British (WB) MSM (n = 203) were used as a comparative group. BME MSM were significantly more likely to report unprotected anal intercourse with casual male partners in the preceding three months (P = 0.0016) and were more likely to report female sexual partners (P = 0.0018). Rectal gonorrhoea was more common in WB MSM (P = 0.02). Numbers of other bacterial STIs and HIV infection were similar in both groups. The higher reported rates of risk behaviour in BME MSM are of concern and support the need for focussed sexual health promotion.

Would offering rapid point-of-care testing or non-invasive methods improve uptake of HIV testing among high-risk genitourinary medicine clinic attendees? A patient perspective

While most genitourinary (GU) medicine clinics achieve a high uptake for testing HIV in new patients, they may still miss testing those at highest risk. Point-of-care testing (POCT) and salivary samples are acceptable and feasible but have not yet been shown to increase uptake among high-risk patients (HRP). This study aimed to describe reasons why HRP decline HIV testing and whether offering POCT along with standard testing would increase the uptake of testing HIV in two London GU medicine clinics. Anonymous self-administered questionnaires were offered to all new and rebooked patients. Eight hundred and ninety-nine questionnaires were analysed of which 598 were HRP. Uptake of HIV testing was 77.1% among HRP and 65.8% among the rest. A total of 51.1% of HRP who declined HIV testing said they would be more likely to accept a POCT and 32.8% a salivary test. Introduction of rapid POCT for HIV would increase patient's choice and may increase the likelihood of HRP accepting an HIV test.

Disclosure of anogenital warts to sexual partners

Objectives:To investigate psychological functioning, relationship factors, stigma perception, disclosure outcomes and regret about the disclosure decision in people being treated for anogenital warts, comparing disclosers and non-disclosers and evaluating the...

Sexual health services for South Asians in London, UK: a case–control study

National guidance on sexual health in England recommends service development to meet the specific needs of ethnic minority populations. Our aim was to evaluate mode of referral, number of sexually transmitted infections (STIs) diagnosed, and the offering and uptake of HIV testing in patients of South Asian ethnicity. A retrospective case-control study was undertaken in two London genito-urinary (GU) medicine clinics. There were 250 case-control pairs with approximately equal numbers of men and women. South Asians were less likely to have an STI (Odds ratio [OR] 0.66, 95% confidence interval [CI] 0.45, 0.97) or to report risk factors for HIV (OR 0.45, 95% CI 0.28, 0.71). Offering and uptake of HIV antibody testing were high in both South Asian and non-South Asian groups (OR 0.62, 95% CI 0.27, 1.51). South Asians were significantly more likely than controls to have been referred by other medical services rather than self-referred (OR 2.00, 95% CI 1.32, 3.01), which is in keeping with poorer access to GU medicine services in London.

Shigella sonneiOutbreak among Homosexual Men, London

<i>Shigella sonnei</i>Outbreak among Homosexual Men, London

Delivering results to clients: a question of satisfying needs or desires?

Demand for genitourinary (GU) medicine services is outstripping supply. Improving efficiency can modulate the supply side of the equation, e.g. decreasing the number of clients having to return for their results. This survey explored how clients at two central London GU medicine clinics would like to receive their results and their views were reflected against what was offered by London GU medicine clinics. There was a significant difference between the result delivery services that the clients wanted and what the clinics provided (P <0.0001, chi(2)). Of the clients, 92% wanted to know their results regardless of outcome whereas 22% of London clinics would only inform clients of positive results. This study questions the importance and feasibility of patient choice, an important aspect of the National Strategy for Sexual Health and HIV. Clinics may not individually be able to provide choice but between them, they do provide a wide range of alternatives for the client.

Declining prevalence of STI in the London sex industry, 1985 to 2002

Objectives: To describe major changes in the London sex industry between 1985 and 2002 and assess the implications for sexually transmitted infection (STI) risk. Method: A descriptive study comparing women...