How ready are GPs to do STI work?

GPs are being pressed to become involved with STI testing, but how feasible is this? Rachel Liddle investigates.

The pressure is growing for GPs to become more involved in STI testing, however, the role of general practice in detection, treatment and prevention of STIs is a grey area.

The most recent data from the Health Protection Agency shows that the number of STI diagnoses made in UK GUM clinics continue to increase; 376,508 new infections were reported in 2006, compared with 324,196 in 2002.

In 2006, one million people attended GUM clinics for testing. The National Chlamydia Screening Programme for under-25s is being rolled out across England, with both GPs and GUM clinics expected to carry out the first-catch urine tests. So far, 51 per cent of PCTs are running the programme and 34 per cent are about to start.

More GP testing
Additionally, in a draft public health guideline published in November 2007, NICE called on GPs and practice nurses to discuss sexual health in consultation with under-18s.

It said GPs should identify and offer STI tests to patients considered at risk.

More recently, CMO Sir Liam Donaldson wrote to GPs urging them to do more tests for HIV to improve rates of early diagnosis in the UK (GP, 5 October).

But with no quality framework incentive to carry out STI tests are GPs doing this work?

Findings from a GP survey of 226 GPs showed that almost half still saw STI testing as a job for GUM clinics. A quarter said practice nurses could carry out the tests, but only 13 per cent said GPs should carry out the majority of STI tests.

The survey found a huge variation in how often tests are being carried out in UK practices.

Total STI screens are rare in general practice. Almost 70 per cent of those surveyed said they never or rarely carry out screens.

While testing for individual STIs varies, chlamydia is tested for most frequently.

Of those questioned 53 per cent said they tested for chlamydia on a weekly basis, and 32 per cent on a monthly basis (see chart).

But only 22.5 per cent of GPs said they checked for gonorrhoea weekly, and 15.8 per cent said they did the test monthly.

Dr Colm O'Mahony, a consultant in sexual health and spokesman for the British Association for Sexual Health and HIV, said GPs should test for gonorrhoea and chlamydia together in a first-catch urine test.

For sexually active patients aged 16 to 17 these tests are the most important.

For those aged 25 and over, a blood test for HIV and syphilis is warranted, he said.

But few GPs appear to be testing for either. Of those surveyed by GP, less than 20 per cent said they tested patients for HIV or syphilis on a weekly or monthly basis.

These rates of testing are unsurprising when 70 per cent of GPs said they usually test for STIs when patients present with symptoms.

Under 8 per cent said the tests are carried out opportunistically and the remainder said they were at the patient's request.

However, the reasons why GPs fail to carry out tests on all eligible patients do not necessarily come down to quality framework payments.

Further STI checks
When asked what would make GPs carry out more STI checks in their practice, over half said more time and 40 per cent said extra staff.

GP also found that 43 per cent said that STI testing would need to be in the quality framework and 37 per cent called for a national screening programme if STI checks were to become a routine part of general practice.

But Dr Richard Ma, north London GP and member of RCGP sex, drugs and HIV working party, said GPs should expect to become more involved in STI care over the next few years.

'We'll be seeing a lot more testing in general practice on patients without symptoms and symptomatic cases,' he said.

Management of uncomplicated cases will also be expected, added Dr Ma. 'There are a small number of STIs and they are easy to manage.'

He said it is a common misconception that STI tests, especially those for HIV, need lengthy pre-test counselling.

'Once you understand the main issues, it doesn't have to take the full 10 minutes,' he said.

Nevertheless, inconsistencies among available pathology services and a lack of technology can make STI testing more difficult for GPs, but GPs should still be asking patients about sexual health, said Dr Ma.

So while the role of general practice in sexual health remains unclear for the moment, it seems that the push towards STI checks by GPs and practice nurses is likely to become concrete.

STI checks
Percentage of GPs testing for STIs on a weekly basis

  • Trichomona vaginali 42.6%
  • Gonorrhoea 22.5%
  • Hepatitis B 14.0%
  • Hepatitis C 12.3%
  • HIV 8.5%
  • Syphilis 8.1%
  • Full screen 2.3%

Source: GP survey.

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