Journal of Infection (I992) z4, 43-47
HIV testing and a s s e s s m e n t o f risk o f other sexually transmitted diseases C. T h o m p s o n , * ~ F. M. C o w a n , t C. M. B i s s e t t and R. P. Brettle~*
Genitourinary Medicine Unit, Department of Medicine, Royal Infirmary of Edinburgh and af Communicable Diseases Unit, City Hospital, Edinburgh, Scotland, U.K. Accepted for publication 17 July I99I Summary
The risk factors for infection with the human immunodeficiency virus (HIV) were assessed in individuals attending two different HIV antibody testing clinics: Genitourinary Medicine (GUM) and an HIV counselling and screening clinic (CSC) The risk of acquiring other sexually transmissible infections (STD) was also assessed, and all patients were offered STD screening. Fewer STDs were found in CSC patients than in G U M patients, but the results highlight the need to be aware of the possibility of other STDs whenever and wherever HIV antibody testing is undertaken.
Introduction In October I985, testing for antibody to h u m a n immunodeficiency virus (HIV) became freely available in E d i n b u r g h . At this time, a Counselling and Screening Clinic for individuals concerned about H I V infection was established at the City Hospital as an alternative to the service provided at the D e p a r t m e n t of G e n i t o u r i n a r y Medicine, both of which were designed to support the donor deferrment policy of the Scottish National Blood T r a n s f u s i o n Service. In E d i n b u r g h , the majority of k n o w n H I V infected individuals are, or have been, intravenous drug users ( I D U ) . t However, it has been shown that amongst individuals seeking an H I V test at G U M , there is a high prevalence of other sexually t r a n s m i t t e d diseases, even when the risk of H I V infection was considered to be non-sexual. 2' 3 T h i s provoked some concern about the prevalence of S T D in those seeking only an H I V test, and a prospective study was established to assess the need for S T D screening in this group of people. T h e results have i m p o r t a n t implications for H I V testing u n d e r t a k e n o u t w i t h G U M clinics.
Patients and method Between 7 September and 3I D e c e m b e r I988, consecutive new clients attending C S C were offered standard S T D screening 4 in addition to the routine H I V pretest counselling. T h e risk factors for H I V infection were assessed (Table I), and the likelihood of concurrent S T D scored as nil, low or high, using the criteria listed in Table II. ~: Address correspondence to: Dr C Thompson, Consultant Physician, Department of Genitourinary Medicine, Victoria Hospital, Kirkaldy, Fife, Scotland, U.K.
oi63-4453/92/oioo43 +05 $03.00/0
© I992 The British Society for the Study of Infection
c. T H O M P S O N
44
ETAL.
T a b l e I H I V risk factors for seronegative patients CSC Intravenous drug user ( I D U ) Heterosexual contact of I D U Homosexual/bisexual Contact of bisexual Blood contamination/needlestick injury Heterosexual contact of low risk person Heterosexual contact of prostitute Prostitute Heterosexual contact of known H I V seropositive person Heterosexual assault Visa Other Total
74
5*
(%)
GUM
(%)
7
i
i
15
4
4
8"1"
9
15
17
I
I
I
I
IO~
14
I
I
35 I
47 I
53 4
6o 4
0
0
0
0
0
0
2
2
I I
I I
6 0
7 0
I
I
2
2
II
89
* Three also heterosexual contact of I D U .
t One also IDU and prostitute. :~ One also e x - I D U .
N e w patients attending G U M requesting an H I V test in the same period of time were similarly assessed for H I V risk factors, likelihood of S T D and its prevalence. Results
D u r i n g the study period I IO consecutive n e w patients attended C S C , b u t five were counselled as in-patients and one was later f o u n d to have attended before. T h e s e six were excluded from the study. O f the remaining IO4 clients, 29 ( 2 8 % ) did not proceed with H I V testing (26 H I V status u n k n o w n ; three previously tested positive). This resulted in 75 clients being tested for H I V antibody and assessed for S T D screening, which f o r m e d a group comparable with those H I V antibody tested at G U M . One homosexual m a n had a positive test result, while the other 74 were seronegative for H I V . T h e r e were 44 (59 %) m e n with a mean age of 3o (17-62) years and 31 ( 4 1 % ) women, mean age 27 (18-46) years. T h e H I V risk factors for the 74 seronegative individuals are shown in T a b l e I. N o n e of these clients had s y m p t o m s suggestive of S T D . Six (one seropositive and five seronegative) had had S T D screening since their 'risk' thus 69 were offered screening, of w h o m I9 (28 %) accepted. O f these, five defaulted before the screening tests could be performed. T h e assessed S T D risk of the C S C clients and the results of screening are shown in T a b l e II. T w o clients were f o u n d to have S T D : one had genital warts and one had gonorrhoea. N i n e t y two of IO28 n e w G U M patients had an H I V test (89 were seronegative and three seropositive). T w o of the seropositive individuals had been H I V tested elsewhere, and were thus excluded from the study, this resulted in 90 patients being studied: 60 ( 6 7 % ) men, mean age 27 ( I 6 - 4 6 ) years; 30 ( 3 3 % ) women, mean age 26 (15-46) years; the one seropositive
H I V risk t h r o u g h injection drug use ( I D U ) but no casual sex H I V risk sexual b u t from regular partner or partner from more t h a n I year ago or ' safer s e x ' or condoms used
H I V risk from casual sexual partner H I V risk from I D U b u t also casual sex within previous year H I V risk sexual but screening too m u c h for client to cope with at initial visit
Low
High
75
22
36
I7"
CSC
(29)
(48)
(23)
(%)
90
41
46*
3
GUM
Assessed S T D risk
(46)
(5I)
(3)
(%)
5 (26 %)
o
5
0
2 ( i i %)
]"
o
0
Number of patients in w h o m STD detected
cases; gonorrhoea--3
I4 ( 7 4 % )
7
6
I
Number of patients in w h o m STD screen performed
* Including one seropositive for HIV J- O n e c a s e o f g o n o r r h o e a ; o n e c a s e o f g e n i t a l w a r t s . 35 i n f e c t i o n s in 3o p a t i e n t s : g e n i t a l w a r t s - - x 2 c a s e s ; n o n - g o n o c o c c a l u r e t h r i t i s - - i 3 v a g i n a l i s - - i c a s e ; g e n i t a l h e r p e s - - 3 c a s e s ; l a t e n t s y p h i l i s - - i case.
Total
H I V risk from blood contamination/needlestick S T D screen already p e r f o r m e d elsewhere H I V request for visa/insurance purposes
NIL
Scoring criteria for S T D risk
Number of patients defaulted from STD screen
A t C S C in I9 patients
80
36
42
2
(89%)
Number o f patients in w h o m STD screen performed
3o5 (33 %)
I4
I5
I
Number of patients in w h o m STD detected
cases; scabies--2 cases ; Trichomonas
io ( i i %)
5
4
I
Number o f patients in w h o m STD screen declined
A t G U M in 90 patients
Results of S T D screening
Table II S T D risk assessment and screening results
4~
46
c. THOMPSON
ET AL.
patient was homosexual and assessed as having a ' l o w ' risk for S T D . T h e H I V risk factors are shown in T a b l e I. T e n asymptomatic patients ( I I %), eight male and two female, declined S T D screening at G U M , b u t an S T D was detected in 30 (38 %) of the 80 patients screened (Table II). O f these, 25 (83 %) had s y m p t o m s suggestive of S T D , as did i6 (32 %) of the 50 patients in w h o m no S T D was detected. T h e main reported s y m p t o m s were genital discomfort, vaginal or urethral discharge and presence of warts. Discussion
At both sites, the majority of patients were H I V seronegative when tested. T h e r e is p r o b a b l y some patient selection as to which clinic is attended, according to presence or absence of s y m p t o m s and perceived H I V risk factors. All C S C attenders were asymptomatic, whereas 4 1 / 9 o (46 %) G U M patients had s y m p t o m s of S T D . M o r e I D U s and their partners, and recipients of needlestick injuries or blood contamination attended C S C , and m o r e homosexuals and bisexuals, and victims of sexual assault attended G U M (Table I). T h e r e was a fairly equal distribution of individuals whose H I V risk was heterosexual contact with a non-high risk person, and these f o r m e d the largest group at both testing sites. It is of note that there were no identified female prostitutes seen at either clinic during the study period. Possible reasons for this are : poor identification of this particular g r o u p ; prostitutes are n o w using ' safer sex' and therefore do not feel the need to be H I V tested; prostitutes do not wish to know their H I V status. A C S C , 19/58 (33 %) of clients at risk of S T D requested screening, b u t of these, 26 % defaulted once they had received a negative H I V test result. All of these defaulters were thought to have a ' l o w ' risk of S T D . O f those screened, twice as m a n y patients at G U M (37 %) were f o u n d to have an S T D , compared with C S C ( 1 4 % ) but, whereas at C S C both the patients were at ' h i g h ' risk of S T D , in G U M they were distributed evenly b e t w e e n ' l o w ' and 'high '. It is worth noting that two of the patients f o u n d to have an S T D (one at each clinic) were concerned about H I V because of sexual contact with an I D U . T h e assessment of possible S T D risk in the G U M setting as d e t e r m i n e d b y the criteria used here is not a reliable predictor of prevalence of S T D (sensitivity = o'46; specificity = 0"56). A m o n g s t the small n u m b e r of C S C clients accepting S T D screening, assessment of risk had a sensitivity of I.OO and specificity of 0"58. H o w e v e r , the n u m b e r s involved are so small that no firm conclusions can be drawn, although a trend associating prevalence of infection with 'high risk' may be suggested. Patients wishing an H I V test m a y choose to attend the C S C or their General Practitioner, rather than G U M , depending on their perceived risk of infection, particularly if asymptomatic. It is therefore important to be aware of other S T D s whenever H I V testing is undertaken outwith the Genitourinary Medicine setting. Ideally immediate S T D screening should be p e r f o r m e d because of the high default rate. An alternative approach however, if S T D screening is not readily available, w o u l d be the use of some form of assessment
H I V testing and risk of other S T D
47
as set out here to identify those individuals at high risk of an S T D other than H I V infection. Such an a p p r o a c h , if applied to hospitals and G P s ' surgeries, w o u l d help doctors unfamiliar with the p r o b l e m not to overlook other S T D s w h e n testing for H I V . T h i s assessment w o u l d also be of use in identifying those patients r e q u i r i n g health education to p r e v e n t f u r t h e r spread o f S T D . (We wish to thank the staff of the Department of Bacteriology, City Hospital, and the Genitourinary Medicine Unit, Royal Infirmary of Edinburgh, for their assistance.) References
I. AIDS News supplement. COS Weekly Report; CDS 88/02. 2. Sankar K, Pattman RS. Value of screening for sexually transmitted diseases in patients requesting HIV testing. Lancet I987; ii: 917. 3. Thompson C, McIver A. HIV counselling : change in trends in public concern. Health Bull I988; 46: 237-45. 4. Robertson DHH, McMillan A, Young H. Clinicalpractice in sexually transmissible diseases. Edinburgh: Churchill Livingstone, I989: 92-Io7.
HIV testing and a s s e s s m e n t o f risk o f other sexually transmitted diseases C. T h o m p s o n , * ~ F. M. C o w a n , t C. M. B i s s e t t and R. P. Brettle~*
Genitourinary Medicine Unit, Department of Medicine, Royal Infirmary of Edinburgh and af Communicable Diseases Unit, City Hospital, Edinburgh, Scotland, U.K. Accepted for publication 17 July I99I Summary
The risk factors for infection with the human immunodeficiency virus (HIV) were assessed in individuals attending two different HIV antibody testing clinics: Genitourinary Medicine (GUM) and an HIV counselling and screening clinic (CSC) The risk of acquiring other sexually transmissible infections (STD) was also assessed, and all patients were offered STD screening. Fewer STDs were found in CSC patients than in G U M patients, but the results highlight the need to be aware of the possibility of other STDs whenever and wherever HIV antibody testing is undertaken.
Introduction In October I985, testing for antibody to h u m a n immunodeficiency virus (HIV) became freely available in E d i n b u r g h . At this time, a Counselling and Screening Clinic for individuals concerned about H I V infection was established at the City Hospital as an alternative to the service provided at the D e p a r t m e n t of G e n i t o u r i n a r y Medicine, both of which were designed to support the donor deferrment policy of the Scottish National Blood T r a n s f u s i o n Service. In E d i n b u r g h , the majority of k n o w n H I V infected individuals are, or have been, intravenous drug users ( I D U ) . t However, it has been shown that amongst individuals seeking an H I V test at G U M , there is a high prevalence of other sexually t r a n s m i t t e d diseases, even when the risk of H I V infection was considered to be non-sexual. 2' 3 T h i s provoked some concern about the prevalence of S T D in those seeking only an H I V test, and a prospective study was established to assess the need for S T D screening in this group of people. T h e results have i m p o r t a n t implications for H I V testing u n d e r t a k e n o u t w i t h G U M clinics.
Patients and method Between 7 September and 3I D e c e m b e r I988, consecutive new clients attending C S C were offered standard S T D screening 4 in addition to the routine H I V pretest counselling. T h e risk factors for H I V infection were assessed (Table I), and the likelihood of concurrent S T D scored as nil, low or high, using the criteria listed in Table II. ~: Address correspondence to: Dr C Thompson, Consultant Physician, Department of Genitourinary Medicine, Victoria Hospital, Kirkaldy, Fife, Scotland, U.K.
oi63-4453/92/oioo43 +05 $03.00/0
© I992 The British Society for the Study of Infection
c. T H O M P S O N
44
ETAL.
T a b l e I H I V risk factors for seronegative patients CSC Intravenous drug user ( I D U ) Heterosexual contact of I D U Homosexual/bisexual Contact of bisexual Blood contamination/needlestick injury Heterosexual contact of low risk person Heterosexual contact of prostitute Prostitute Heterosexual contact of known H I V seropositive person Heterosexual assault Visa Other Total
74
5*
(%)
GUM
(%)
7
i
i
15
4
4
8"1"
9
15
17
I
I
I
I
IO~
14
I
I
35 I
47 I
53 4
6o 4
0
0
0
0
0
0
2
2
I I
I I
6 0
7 0
I
I
2
2
II
89
* Three also heterosexual contact of I D U .
t One also IDU and prostitute. :~ One also e x - I D U .
N e w patients attending G U M requesting an H I V test in the same period of time were similarly assessed for H I V risk factors, likelihood of S T D and its prevalence. Results
D u r i n g the study period I IO consecutive n e w patients attended C S C , b u t five were counselled as in-patients and one was later f o u n d to have attended before. T h e s e six were excluded from the study. O f the remaining IO4 clients, 29 ( 2 8 % ) did not proceed with H I V testing (26 H I V status u n k n o w n ; three previously tested positive). This resulted in 75 clients being tested for H I V antibody and assessed for S T D screening, which f o r m e d a group comparable with those H I V antibody tested at G U M . One homosexual m a n had a positive test result, while the other 74 were seronegative for H I V . T h e r e were 44 (59 %) m e n with a mean age of 3o (17-62) years and 31 ( 4 1 % ) women, mean age 27 (18-46) years. T h e H I V risk factors for the 74 seronegative individuals are shown in T a b l e I. N o n e of these clients had s y m p t o m s suggestive of S T D . Six (one seropositive and five seronegative) had had S T D screening since their 'risk' thus 69 were offered screening, of w h o m I9 (28 %) accepted. O f these, five defaulted before the screening tests could be performed. T h e assessed S T D risk of the C S C clients and the results of screening are shown in T a b l e II. T w o clients were f o u n d to have S T D : one had genital warts and one had gonorrhoea. N i n e t y two of IO28 n e w G U M patients had an H I V test (89 were seronegative and three seropositive). T w o of the seropositive individuals had been H I V tested elsewhere, and were thus excluded from the study, this resulted in 90 patients being studied: 60 ( 6 7 % ) men, mean age 27 ( I 6 - 4 6 ) years; 30 ( 3 3 % ) women, mean age 26 (15-46) years; the one seropositive
H I V risk t h r o u g h injection drug use ( I D U ) but no casual sex H I V risk sexual b u t from regular partner or partner from more t h a n I year ago or ' safer s e x ' or condoms used
H I V risk from casual sexual partner H I V risk from I D U b u t also casual sex within previous year H I V risk sexual but screening too m u c h for client to cope with at initial visit
Low
High
75
22
36
I7"
CSC
(29)
(48)
(23)
(%)
90
41
46*
3
GUM
Assessed S T D risk
(46)
(5I)
(3)
(%)
5 (26 %)
o
5
0
2 ( i i %)
]"
o
0
Number of patients in w h o m STD detected
cases; gonorrhoea--3
I4 ( 7 4 % )
7
6
I
Number of patients in w h o m STD screen performed
* Including one seropositive for HIV J- O n e c a s e o f g o n o r r h o e a ; o n e c a s e o f g e n i t a l w a r t s . 35 i n f e c t i o n s in 3o p a t i e n t s : g e n i t a l w a r t s - - x 2 c a s e s ; n o n - g o n o c o c c a l u r e t h r i t i s - - i 3 v a g i n a l i s - - i c a s e ; g e n i t a l h e r p e s - - 3 c a s e s ; l a t e n t s y p h i l i s - - i case.
Total
H I V risk from blood contamination/needlestick S T D screen already p e r f o r m e d elsewhere H I V request for visa/insurance purposes
NIL
Scoring criteria for S T D risk
Number of patients defaulted from STD screen
A t C S C in I9 patients
80
36
42
2
(89%)
Number o f patients in w h o m STD screen performed
3o5 (33 %)
I4
I5
I
Number of patients in w h o m STD detected
cases; scabies--2 cases ; Trichomonas
io ( i i %)
5
4
I
Number o f patients in w h o m STD screen declined
A t G U M in 90 patients
Results of S T D screening
Table II S T D risk assessment and screening results
4~
46
c. THOMPSON
ET AL.
patient was homosexual and assessed as having a ' l o w ' risk for S T D . T h e H I V risk factors are shown in T a b l e I. T e n asymptomatic patients ( I I %), eight male and two female, declined S T D screening at G U M , b u t an S T D was detected in 30 (38 %) of the 80 patients screened (Table II). O f these, 25 (83 %) had s y m p t o m s suggestive of S T D , as did i6 (32 %) of the 50 patients in w h o m no S T D was detected. T h e main reported s y m p t o m s were genital discomfort, vaginal or urethral discharge and presence of warts. Discussion
At both sites, the majority of patients were H I V seronegative when tested. T h e r e is p r o b a b l y some patient selection as to which clinic is attended, according to presence or absence of s y m p t o m s and perceived H I V risk factors. All C S C attenders were asymptomatic, whereas 4 1 / 9 o (46 %) G U M patients had s y m p t o m s of S T D . M o r e I D U s and their partners, and recipients of needlestick injuries or blood contamination attended C S C , and m o r e homosexuals and bisexuals, and victims of sexual assault attended G U M (Table I). T h e r e was a fairly equal distribution of individuals whose H I V risk was heterosexual contact with a non-high risk person, and these f o r m e d the largest group at both testing sites. It is of note that there were no identified female prostitutes seen at either clinic during the study period. Possible reasons for this are : poor identification of this particular g r o u p ; prostitutes are n o w using ' safer sex' and therefore do not feel the need to be H I V tested; prostitutes do not wish to know their H I V status. A C S C , 19/58 (33 %) of clients at risk of S T D requested screening, b u t of these, 26 % defaulted once they had received a negative H I V test result. All of these defaulters were thought to have a ' l o w ' risk of S T D . O f those screened, twice as m a n y patients at G U M (37 %) were f o u n d to have an S T D , compared with C S C ( 1 4 % ) but, whereas at C S C both the patients were at ' h i g h ' risk of S T D , in G U M they were distributed evenly b e t w e e n ' l o w ' and 'high '. It is worth noting that two of the patients f o u n d to have an S T D (one at each clinic) were concerned about H I V because of sexual contact with an I D U . T h e assessment of possible S T D risk in the G U M setting as d e t e r m i n e d b y the criteria used here is not a reliable predictor of prevalence of S T D (sensitivity = o'46; specificity = 0"56). A m o n g s t the small n u m b e r of C S C clients accepting S T D screening, assessment of risk had a sensitivity of I.OO and specificity of 0"58. H o w e v e r , the n u m b e r s involved are so small that no firm conclusions can be drawn, although a trend associating prevalence of infection with 'high risk' may be suggested. Patients wishing an H I V test m a y choose to attend the C S C or their General Practitioner, rather than G U M , depending on their perceived risk of infection, particularly if asymptomatic. It is therefore important to be aware of other S T D s whenever H I V testing is undertaken outwith the Genitourinary Medicine setting. Ideally immediate S T D screening should be p e r f o r m e d because of the high default rate. An alternative approach however, if S T D screening is not readily available, w o u l d be the use of some form of assessment
H I V testing and risk of other S T D
47
as set out here to identify those individuals at high risk of an S T D other than H I V infection. Such an a p p r o a c h , if applied to hospitals and G P s ' surgeries, w o u l d help doctors unfamiliar with the p r o b l e m not to overlook other S T D s w h e n testing for H I V . T h i s assessment w o u l d also be of use in identifying those patients r e q u i r i n g health education to p r e v e n t f u r t h e r spread o f S T D . (We wish to thank the staff of the Department of Bacteriology, City Hospital, and the Genitourinary Medicine Unit, Royal Infirmary of Edinburgh, for their assistance.) References
I. AIDS News supplement. COS Weekly Report; CDS 88/02. 2. Sankar K, Pattman RS. Value of screening for sexually transmitted diseases in patients requesting HIV testing. Lancet I987; ii: 917. 3. Thompson C, McIver A. HIV counselling : change in trends in public concern. Health Bull I988; 46: 237-45. 4. Robertson DHH, McMillan A, Young H. Clinicalpractice in sexually transmissible diseases. Edinburgh: Churchill Livingstone, I989: 92-Io7.
