Testing the children of HIV-positive mothers.

We aimed to establish current practice regarding the testing of children of HIV-positive women in two centres in the South Yorkshire HIV Network, UK. Notes were reviewed from 59 women who attended clinic over a three-month period from 01 September 2009 to 30 November 2009. In our sample, only 29 of 52 (56%) children living in the UK who required testing had been HIV tested. Testing rates were high in preschool children (15/15) and fell with age to 2/11 (18%) in the 16-20 years age group. Uptake of testing for children of HIV-positive parents could potentially be improved if testing was incorporated into routine clinic practice as part of the package of care offered to a newly diagnosed individual.

Time taken to undetectable viral load, following the initiation of HAART.

The notes of all HIV patients in Sheffield, registered at the Department of Genitourinary Medicine at the Royal Hallamshire Hospital, who had initiated HAART in 2005 and 2006, were audited. The aim was to determine what percentage of these patients acquired an undetectable viral load within 24 weeks and whether this was greater than 75% in accordance with the BHIVA guidelines. Twenty-nine (78.4%) of the 37 patients who were initiating treatment for the first time had an undetectable viral load after 24 weeks.

Management of under-16-year olds in UK genitourinary medicine clinics: British Co-operative Clinical Group.

In 2004, the management of under-16-year olds in UK genitourinary (GU) medicine clinics was surveyed. Questionnaires were sent to 185 lead GU medicine consultants. A total of 111 questionnaires were returned (60%). Ninety-eight percent of respondents managed young people aged 13-16. Fifty percent managed under 13-year-olds. Twenty-nine percent of respondents ran dedicated young people's clinics. Ninety-eight percent were aware of the National Guidelines, and 74% had adopted them. Fifty-seven percent had a named departmental child protection lead. Thirty-seven percent of consultants had received training specific to child protection issues in GU medicine. Improvements had been made since a similar survey published in 2001, but the need for further training was still apparent.

Confidentiality is essential if young people are to access sexual health services.

A survey was undertaken to determine the importance of confidentiality of sexual health clinics to young people, and their preferences for service provision. A questionnaire was given to school attenders in year 9 (age 13-14 years) at four comprehensive schools. Class leaders assisted students with literacy or language difficulties. Two hundred and ninety five questionnaires were distributed and all were returned (male 143 (48.5%), female 152 (51.5%). In all 199 (67.5%) had never used sexual health services. The importance of confidentiality (asked in two differently worded questions) was rated as 8.84 and 8.59 (mean) on a scale of 1 (not important) to 10 (very important), 166 (56.3%) rated confidentiality as most important feature of service and 254 (86.1%) were more likely to use a service if it was confidential; 161 (54.6%) would not use service if it were not confidential. Two hundred and sixty-six (90.2%) would give honest answers in a confidential service; 186 (63.1%) would not attend if they thought that child protection services would be informed; 136 (46.1%) would not want general practitioner informed of attendance; 209 (70.8%) would like regular sexual health check ups; 150 (50.8%) would prefer a young people clinic, but only 105 (35.6%) prefer a 'one-stop shop'. This study shows that confidentiality is extremely important to young people considering using a sexual health service. It is the first UK study to show that if confidentiality is lost, young people may not attend, or may not be honest when they utilize a sexual health service. This is particularly relevant at the moment in light of the threat to confidentiality for young people attending sexual health services.

Regression of invasive conjunctival squamous carcinoma in an HIV-positive patient on antiretroviral therapy.

Case history of an African woman presenting with advanced HIV and a painful conjunctival lesion is presented. A conjunctival biopsy revealed invasive squamous cell carcinoma, with orbital invasion on computed tomography scan. She was commenced on antiretroviral therapy. She refused surgery to remove the eye and orbital contents (exenteration), and was referred to palliative care. Gradually, her immune status and ocular symptoms improved. At ophthalmic review, the tumour had apparently completely regressed. This unprecedented phenomenon may be due to antiretroviral therapy. Discussion covers conjunctival carcinoma and behaviour of HIV-related tumours with antiretroviral therapy. Antiretroviral drugs may offer a better alternative to disfiguring surgery in the future.

Are women with chlamydia infection who self-refer to genitourinary medicine clinics different?

The objective of this study was to explore whether patients with Chlamydia trachomatis infection who self-refer to genitourinary medicine clinics have different demographic characteristics to those who initially attend other agencies. This study took place in three genitourinary medicine clinics from Birmingham, Nottingham and Sheffield. Demographic and post-code data were collected from female patients diagnosed with genital chlamydia infection in 2000. Townsend scores, as an index of socioeconomic status, were derived from post-codes from a subset of the cohort (from Birmingham). Comparison was made between those who were diagnosed by genitourinary medicine clinics and those diagnosed in the community and referred to genitourinary medicine clinics for further management. Data were collected from 1047 genitourinary medicine and 816 non-genitourinary medicine women, of whom 686 (84.1%) attended genitourinary medicine clinics following referral. After excluding those with incomplete data, 1614 (987 genitourinary medicine and 627 non-genitourinary medicine) patients were included in the study. Using logistic regression analysis, we were unable to demonstrate any significant differences in age or Townsend scores between genitourinary medicine and non-genitourinary medicine patients. However, significantly more Black Caribbean (odds ratio [OR] = 2.72, 95% confidence interval [CI]: 2.22, 3.20) and single women (OR = 1.97, 95% CI: 1.64, 2.29) self-referred to genitourinary medicine clinics compared with other health-care settings. This trend was consistent between Birmingham and Nottingham. In Sheffield, there was no difference in marital status. Ethnicity was not a factor as there were no Black Caribbean patients in the Sheffield cohort. Women who were diagnosed with genital chlamydia infection in genitourinary medicine clinics have some different demographic characteristics to those who were diagnosed in the community.

Trichomonas vaginalis in a Sheffield genitourinary medicine department.

The case-notes of all patients who were diagnosed with a first episode of Trichomonas vaginalis (TV) between 1 October 2002 and 30 September 2003 were reviewed. A total of 78 patients were suitable for inclusion in the study. Analysis of their notes revealed that, although the majority of patients presented with symptoms, 15% (n=12) of cases were asymptomatic. A raised vaginal pH was found in 94% (n=47) of the patients in whom it was measured. In all, 97% (n=76) of patients received treatment in accordance with UK national guidelines and, in those tested, initial treatment was found to be 95% (n=57) successful. Treatment of at least one contact could only be confirmed in 27% (n=21) of cases. The implications for future management of TV are discussed.

Screening, diagnosis and management of early syphilis in genitourinary medicine clinics in the UK.

New diagnoses of syphilis in the UK increased eight-fold between 1997 and 2002. This study, conducted in 2002, demonstrated that 31% of clinics were not confident of their expertise to obtain an adequate specimen for dark ground microscopy (DGM), and 35% were not confident of their expertise to detect treponemes on DGM. In all, 64% of clinics had observed adherence problems in HIV-positive patients treated with parenteral regimens, as against 42% with oral regimens. Also, 51% of clinics waited more than a week for the results of initial serological tests for syphilis, and 88% of clinics waited more than a week for confirmatory test results. Other concerns include the failure to perform syphilis serology consistently whenever HIV-positive patients were at risk, and the widespread use of doxycycline as a therapy for syphilis in HIV-positive patients despite concerns that this is not known to be fully treponemicidal in cerebrospinal fluid.

Introduction of a proforma in the management of under age attendees at a genitourinary clinic.

The aim of this review was evaluation of a recently developed proforma for improving assessment and management of patients under the age of 16 in the genitourinary (GU) medicine clinic. A case-note review of all under-16s attending between June 2000 and March 2001 was undertaken (109 patients). Comparison with review from 1998 prior to proforma introduction was carried out. In all, 99 proformas were completed. Fewer young patients were seen solely by junior doctors since proforma introduction (27-45%) (P=0.012), more were referred to health advisors (79% versus 66%) (P = 0.056),but follow-up remains suboptimal (72% versus 78%). Possibility of abuse was assessed in 102 patients (17 cases of non-consensual sex versus six in 1998). In all, 54% were using no contraception and only 21% were consistently using barrier methods; 41% had sexually transmitted infections diagnosed. The proforma is useful for collecting data and directing management when completed fully, and has revealed greater numbers of children involved in risky behaviour and abuse.

The impact of pump-priming funding on genitourinary medicine and modernization of services.

Genitourinary (GU) medicine services are under increasing pressure due to increased workload. The Department of Health responded to this crisis by allocating pump-priming funding of ?5 million direct to GU medicine clinics in 2002-03. A survey was performed of all clinics in England to determine if funding was received, its utilization and the extent of modernization of services. Response rate was 71% (147 of 206 clinics), with 95% (140) receiving their allocation. Additional clinics were instated by 54% (74/137) and of these 51% (35/69) had thus reduced their waiting times. Extensive modernization of services was under way, with 89% (130/146) reducing proportion of follow-up attendances, 87% (127/146) extending the nurse role and the majority of clinics looking at developing or extending their clinical networks. This study has shown the direct benefit of increased funding allocated to GU medicine and the extent of modernization under way.

What are the needs of asylum seekers attending an STI clinic and are they significantly different from those of British patients?

To elicit the needs of asylum seekers attending the Royal Hallamshire genitourinary medicine clinic for the first time in 2002 and whether these differed from British patients, a search of patient records for 2002 identified 43 asylum seekers (21 female, 22 male) who were paired with 43 British patients matched by age and sex (mean age 27.9, range 15-56). The needs of the patients were ascertained by retrieving answers to predetermined questions from the paper records. Asylum seekers had 166 appointments while British patients had 113 (P = 0.091) and 21 DNAs (did not attend appointment), compared with seven British DNAs (P = 0.071). Twenty-eight asylum seekers and no British patients needed an interpreter (P < 0.01). Five of the 18 eligible asylum seeker females had an up-to-date smear compared with 13 British females (P = 0.008). Nineteen asylum seekers reported sexual violence compared with none of the British patients (P < 0.011); 15 of these asylum seekers were receiving/had requested counselling. There was no significant difference in the numbers of pregnant women, commercial sex workers and intravenous drug users, and patients reporting a previous history of sexually transmitted infection. There are some differences between the needs of asylum seekers and British patients; the most noticeable are the use of interpreters, the reporting of sexual violence, the need for counselling and the number of women without up-to-date smears. A larger study may highlight more differences.

General practitioners and the National Strategy on Sexual Health and HIV.

To determine general practitioners' knowledge of, and opinions on, the National Strategy for Sexual Health and HIV and whether they intend to provide Level 1 and 2 HIV/STI services, a self-administered questionnaire was sent to one partner from 155 general practices in Sheffield and North Derbyshire in November 2001. Response rate was 57% (88). Forty-eight (55%) GPs aware of strategy but 53 (60%) had no knowledge of what it involved. LEVEL 1. Sixty-two (71%) felt confident in providing advice on STI prevention and 46 (52%) on HIV. Nine (10%) GPs provide HIV testing and 29 (33%) anticipate doing so but 24 (83%) require staff training and 20 (70%) increased funding. All Level 1 STI services are provided by 60 (68%) practices and 72 (82%) anticipate providing. LEVEL 2. Thirty-nine (45%) anticipate testing and treating STIs but only nine (10%) will undertake partner notification. Resources required are training, nine (60%) and funding, nine (60%). The main reasons for not offering in the future were too busy 58 (72%) and lack of demand 25 (31%). Many GPs are unaware of the strategy but most anticipate providing Level 1 STI services. Less than half anticipate offering HIV testing. Although 45% of GPs may provide Level 2 care, it is unlikely to include partner notification. Many GPs are too busy and require extra training and funding. These needs must be addressed if the Strategy is to be implemented.

Medical workforce speciality review for genitourinary medicine 2002/2003: England, Wales, Northern Ireland and Scotland.

This document is an updated version of that produced in October 2001 and addresses medical workforce needs for the speciality of genitourinary medicine (GUM) for the next 10 years. Data on current consultant numbers, working patterns and retirement are based on information from the Royal College of Physicians (RCP) Workforce Unit annual census undertaken on 30 September 2001. Information on specialist registrars (SpRs) is from the Joint Committee on Higher Medical Training and the GUM Specialist Registrars Group. Senior house officer data are from the RCP's General Professional Training department. Data on non-consultant career grade doctors is from the Association of Genitourinary Medicine Survey and the GUM Non-Consultants Career Grade Group. Data on incidence of sexually transmitted infections (STIs) are from KC60 returns on STIs collected from GUM clinics by the Communicable Diseases Surveillance Centre. There is considerable movement of doctors in GUM between countries in the UK both during progression from SpR to consultant and at the consultant level. Data are therefore presented as amalgamated UK data and also by country (Table 1). It is essential that workforce planning takes this lateral movement into consideration when undertaking calculations for future workforce requirements. The speciality continues to have inadequate consultant numbers and funding is also required to provide adequate number of non-consultant career grade sessions.

Psychiatric side effects of ofloxacin used in the treatment of pelvic inflammatory disease.

The Clinical Effectiveness Group of the Medical Society for the Study of Venereal Diseases and the Association of Genitourinary Medicine published guidelines on the management of pelvic inflammatory disease in 1999. Subsequently, the use of ofloxacin has increased in our department. However, ofloxacin can cause serious psychiatric side effects, particularly in those with a past psychiatric history. This is of relevance to genitourinary medicine (GUM) physicians as there is a high prevalence of psychiatric illness amongst patients attending GUM clinics. We present two cases of ofloxacin causing severe psychiatric symptomatology, in one case causing an acute psychotic reaction. It is recommended a psychiatric history is taken prior to prescribing ofloxacin and that consideration is given to alternative therapy for those with previous psychiatric illness.

Use of a leaflet to replace verbal pretest discussion for HIV: effects and acceptability.

OBJECTIVE: To determine the effect of using a leaflet to replace formal verbal pretest discussion and assess its acceptability to patients. SETTING AND METHODS: A leaflet was developed which gave information on all routine tests undertaken at a genitourinary medicine clinic. Information normally given during verbal pretest discussion for HIV was included. The leaflet was given to all new attenders at routine STI clinics. The proportion of patients accepting tests in the 6 weeks before and 4 weeks after the introduction of the leaflet was elicited by case note review. The acceptability of the leaflet was determined by means of a questionnaire given to patients. RESULTS: The use of the leaflet increased the number of patients offered an HIV test from 654 of 1004 (65%) patients to 371 of 397 (94%), p<0.001. It also increased the number tested from 325 (32%) of 1004 patients to 210 of 397 (53%, p<0.001). Men were more likely to be offered an HIV test than women at baseline (342 of 500 men, 68%, v 312 of 504 women, 62%, p=0.036) but after the intervention there was no longer a difference (men 217, 93%, female 154, 94%). The number of men accepting a test increased more than the number of women (139 of 233 men, 60%, 71 of 164 women, 43%, p <0.005). The 79 questionnaires suitable for analysis showed patient views on the leaflet were mainly favourable: easy to understand 73 (92%), clear 70 (89%), absence of difficult words 73 (91%), and right balance of information 68 (86%). CONCLUSIONS: The routine use of a leaflet to replace verbal pretest discussion (PTD) increased the proportion of patients undergoing testing. Part of the increased testing was because physicians were more likely to offer the test, possibly because the time constraints of pretest discussion were removed. This appears to be an acceptable and effective way of increasing HIV testing in GUM clinics but further work is needed to elicit information on non-responders to the questionnaire.

Sexual health needs of the under-16s attending an STI clinic: what are they and are they being addressed?

A retrospective analysis was performed on case notes of patients aged less than 16 years who attended a Department of Genito-Urinary Medicine as a new case in 1998. Seventy-four case notes were reviewed. There was a high rate of sexually transmitted infection (STI) (gonorrhoea six [8%], chlamydia 23 [31%], genital warts nine [12%], trichomonas seven [10%]) and low condom (30, 41%) and other contraceptive use (21 females [35%], six males [60%]). Many female attendees were victims of current or previous sexual abuse (eight, 8%) and/or exploitation, and for a further eight (8%) abuse/exploitation was considered possible; little reference was made to this in the notes. Thirty-three (45%) attendees were seen by junior members of staff, and only 49 (60%) were seen by a health adviser (42 females, seven males [60%]). Young attendees have a high STI rate, low contraceptive use and a significant minority are victims of abuse. Genitourinary medicine clinics need to provide a full sexual health service to this vulnerable group and have guidelines in place to assess for sexual abuse. Recommendations on how to achieve this are given.

Medical workforce speciality review for genitourinary medicine 2001/2002-England, wales, northern ireland and Scotland.

This document addresses medical workforce needs for the speciality of Genitourinary Medicine (GUM) for the next 10 years. Data on current consultant numbers, working patterns and retirement are based on information from the Royal College of Physicians (RCP) Workforce Unit annual census undertaken on 30 September 2000. Information on specialist registrars is from the JCHMT. Senior house officers (SHO) data are from the RCP's General Professional Training department. Data on Non-Consultant Career Grade Doctors is from the Association of Genitourinary Medicine Survey. Data on incidence of Sexually Transmitted Infections (STIs) are from KC60 returns on STIs collected from GUM clinics by CDSC. There is considerable movement of doctors in GUM between countries in the UK both during progression from SpR to consultant and at consultant level. Data are therefore presented as amalgamated UK data and also by country. It is essential that workforce planning takes this lateral movement into consideration when undertaking calculations for future workforce requirements.