CBL - STI

Question 1

What key facts should you establish in the sexual history? [6]

Answer 1

1. Date of last sex
2. Establish facts about sexual practice rather than questions about orientation
3. What gender was this partner? (Male/Female/Both)
4. What type of sex: insertive or receptive, oral or anal or vaginal (in the case of female partner)
5. Did he use condom? Did the partner (if a male partner)?
6. Has he ever had a sexual health check-up and/or HIV test?

Question 2

What tests are generally taken at sexual health clinics? [3]

Answer 2

1. Blood test for
   
   • HIV
   • syphilis
2. NAAT (nucleic acid amplification test) for
   
   • gonorrhoea
   • chlamydia
3. Hepatitis B should be tested for in MSM (blood test) as it can be sexually transmitted and vaccination offered

Question 3

What are the benefits of regular sexual health checks for men having sex with men? [3]

Answer 3

1. Regular checkups allow discussion of preventative measures:
   
   • partner choice,
   • condom use and practicalities (inc free condom provision),
   • safer sex and risky sex,
   • HIV symptom awareness,
   • indications for post exposure prophylaxis against HIV,
   • discussion re-use of alcohol/drugs in relation to sex
2. People often misjudge personal risk
3. Clinics also have a role in psychological support and addressing other concerns such as recreational drug use, ‘coming out’, relationship issues. Can signpost to other services – counseling/addictions team

Question 4

Why would a diagnosis of HSV be a concern - what does it increase your risk of? [3]

Answer 4

1. HSV is a chronic recurrent STI.
   
   1. concern about passing this on to a partner or have unrecognised recurrent symptoms
2. Ulcerations increase risk of other STI acquisition
3. May require suppressive Rx if recurrent ulceration

Question 5

25-year-old man presents with 3 days of increasing tenesmus [a constant desire to defecate], constipation, and anal pain. He now reports passing some mucous and blood rectally.

How would you examine this patient? [6]

Answer 5

1. Full genital, anal and proctoscopic exam as he has symptoms of proctitis.
2. Check the mouth for oral hairy leukoplakia and candida
3. Exclude a generalised skin rash and lymphadenopathy as he is clearly at higher risk of HIV infection.

Question 6

25-year-old man presents with 3 days of increasing tenesmus [a constant desire to defecate], constipation, and anal pain. He now reports passing some mucous and blood rectally.

What tests would you take to investigate this patient? [5]

Answer 6

1. in-clinic microscopy of a rectal swab (gram stain)
2. NAAT (nucleic acid amplification tests) for Chlamydia and gonorrhoea from throat, rectum and urine,
3. culture of a rectal swab ideally by direct plating onto gonococcal isolation agar (for sensitivities)
4. HSV/syphilis PCR (incase of HSV proctitis/syphilis)
5. blood taken for HIV, syphilis, Hep B (if not vaccinated)

Question 7

Why does gonorrhoea usually have multiple drug resistance determinants? [2]

Answer 7

1. Gonorrhoea is naturally transformable so can easily acquire plasmids (sections of bacterial DNA) and genetic material between resistant and sensitive organisms can be transferred.
2. Inappropriate antibiotic use leading to widespread pencillin, tetracycline and quinolone (ciprofloxacin) resistance

Question 8

What can be done to minimize the development of drug resistant strains of gonorrhoea? [4]

Answer 8

1. Rapid accurate diagnosis (microscopy, NAAT)
2. Avoidance of blind therapy with inappropriate drugs
3. Partner notification to limit the onward spread of resistant infection
4. Good regional formulary policies using an antibiotic known to cover >95% infections, Epidemiological monitoring of and policy reaction to resistance data.