Sexual Health Flashcards
Your next patient is a 25 year old man who is here today to discuss his results. He had come to you requesting a ST screening after an overseas travel that he had unprotected sex with multiple partners.
Investigations:
- Chlamydia urine PCR +
- Gonorrhea urine PCR -
- HIV serology -
- Hep B and C serology -
- Syphilis serology -
Tasks:
1. Discuss results and implications (2 minutes)
Counsel regarding the management plan (6 minutes)
Open-ended Question
D: Hi my name is ____. How can I help you today?
R: I’ve just been overseas recently, I’ve had multiple sexual partners. I’ve seen your colleague and he said to see you to discuss the results.
D: I understand. Is there any specific concern that you want me to address?
Discuss Results
D: Before we start, I will be discussing some sensitive topic about your sexual life, is that okay with you?
D: I’d like to reassure you that everything we discuss will be kept confidential
D: We have done some tests checking for sexually transmitted infections. Your gonorrhea test is negative, hepatitis B and C are negative, HIV test is negative, and syphilis test is negative. However, one of your tests has returned positive for chlamydia. The good news is this is the most common STI in Australia and we can easily treat it with antibiotics.
D: Implications of this is first: we have to notify your partners and second: it can lead to more severe infections as it can spread to your testicles and to your urinary tract, and repeated chlamydia infections can lead to infertility
D: Is everything clear up to now?
Counselling
1. Pharmacological Treatment
- We need to treat this infection with antibiotics. We have 2 options: first-line treatment is Doxycycline 100mg capsule, take it twice a days for 7 days. Do you have any allergies to antibiotics? You might get a little bit of tummy upset with this medication, so I need you to take this with a full glass of water and don’t lie down immediately. It might also make you a little bit sensitive to sunlight, so please wear sunscreen when you go out in the sun. Another option is Azithromycin 1g as a single dose, but this is not the preferred option due to the high resistance to the antibiotic.
- While you’re taking this medication, please don’t engage in any sexual intercourse for 1 week, and no sexual intercourse with any of your partners in the last 6 months until they have been tested and treated as necessary
2. Notifications
a. Contact Tracing
- We need to do a contact tracing. We need to notify all of your sexual partners in the last 6 months to see their GP for testing and possible treatment. Our preferred method is a patient referral, which means that you will notify your partners yourself. In case you’re not comfortable with directly notifying your partners, you can use a website called “Let Them Know”. This website will help you notify your partners anonymously.
- If you’re not happy with either of these options, you can pass on the details of your partners to me and I will notify the Department of Health and the sexual health clinic, and they will notify your partners
b. Department of Health
- For chlamydia, the pathology lab will notify the DOH and these notifications are used for statistical purposes and studies
3. Follow-up
a. I would like to review you in 1-week time to check compliance with the medications, and check the contact tracing process
b. I would like to also arrange for a retest for reinfection in 3-month’s-time. We will test for chlamydia again in 3 months to check for reinfection. If any of your partners do not get tested and treated, they might have chlamydia, and you may pick up the infection again if you have intercourse with them. At the same time, I will test for HIV again to check for HIV window period which means that sometimes in the initial stages of HIV infection, the test is unable to detect the virus which is why we repeat it in 3-month’s-time.
4. Patient Education
- Safe Sex Advice
○ Wear condoms during intercourse
○ Maintain a regular stable partner
○ Avoid high risk sexual activity
- I will print out a fact sheet for your further reading regarding safe sex advice from Family planning Victoria and Better Health channel
- Red flags: if you get any pain on passing urine, any discharge from the penis, any pain and swelling in your scrotum, please come back to me
Your next patient is a 25 year old man who is here today to discuss his results. He had come to you requesting a STI screening after an overseas travel that he had unprotected sex with multiple partners.
Investigations:
- Chlamydia urine PCR +
- Gonorrhea urine PCR +
- HIV serology -
- Hep B and C serology -
- Syphilis serology -
Open-ended Question
D: Hi my name is ____. How can I help you today?
R: I’ve just been overseas recently, I’ve had multiple sexual partners. I’ve seen your colleague and he said to see you to discuss the results.
D: I understand. Is there any specific concern that you want me to address?
Discuss Results
D: Before we start, I will be discussing some sensitive topic about your sexual life, is that okay with you?
D: I’d like to reassure you that everything we discuss will be kept confidential
D: We have done some tests checking for sexually transmitted infections. Your hepatitis B and C are negative, HIV test is negative, and syphilis test is negative. However, two of your tests has returned positive, gonorrhea and chlamydia. The good news is these are common STIs in Australia and we can easily treat it with antibiotics.
D: Is everything clear up to now?
Counselling
1. Pharmacological Treatment
- We need to treat both of these infections with antibiotics.
○ For chlamydia, first-line treatment is Doxycycline 100mg capsule, take it twice a days for 7 days. Do you have any allergies to antibiotics? You might get a little bit of tummy upset with this medication, so I need you to take this with a full glass of water and don’t lie down immediately. It might also make you a little bit sensitive to sunlight, so please wear sunscreen when you go out in the sun.
○ For gonorrhea, we’ll treat it with Ceftriaxone 500mg intramuscular injection with 2mL lignocaine which will decrease the pain of the injection.
○ While you’re taking this medication, please don’t engage in any sexual intercourse for 1 week, and no sexual intercourse with any of your partners in the last 6 months until they have been tested and treated as necessary
2. Notifications
a. Contact Tracing
- We need to do a contact tracing. For chlamydia we do it for 6 months, and for gonorrhea, we do it for 2 months. However, since we have both infections, we need to notify all of your sexual partners in the last 6 months to see their GP for testing and possible treatment. Our preferred method is a patient referral, which means that you will notify your partners yourself. In case you’re not comfortable with directly notifying your partners, you can use a website called “Let Them Know”. This website will help you notify your partners anonymously.
- If you’re not happy with either of these options, you can pass on the details of your partners to me and I will notify the Department of Health and the sexual health clinic, and they will notify your partners
b. Department of Health
- For gonorrhea, we need to notify the Department of health
- For chlamydia, the pathology lab will notify the DOH and these notifications are used for statistical purposes and studies
3. Follow-up
a. I would like to review you in 1-week time to check compliance with the medications, and check the contact tracing process
b. Gonorrhea has a high chance of resistance, and this means that the antibiotic may not work. I would like to take another sample to send for culture just in case our usual antibiotic does not work, and I’ll see you in 2 weeks after treatment to do a test for cure to check if the antibiotic worked. I’ll do another test of your first-pass urine and send for gonorrhea PCR.
c. I would like to also arrange for a retest for reinfection in 3-month’s-time. We will test for gonorrhea and chlamydia again in 3 months to check for reinfection. If any of your partners do not get tested and treated, they might have gonorrhea or chlamydia, and you may pick up the infection again if you have intercourse with them. At the same time, I will test for HIV again to check for HIV window period which means that sometimes in the initial stages of HIV infection, the test is unable to detect the virus which is why we repeat it in 3-month’s-time.
4. Patient Education
- Safe Sex Advice
○ Wear condoms during intercourse
○ Maintain a regular stable partner
○ Avoid high risk sexual activity
- I will print out a fact sheet for your further reading regarding safe sex advice from Family planning Victoria and Better Health channel
- Red flags: if you get any pain on passing urine, any discharge from the penis, any pain and swelling in your scrotum, please come back to me
Your next patient is a 40 year old man who has come to your general practice for advice. He is starting a new relationship with a male partner and wants your advice.
Tasks:
1. Counsel your patient regarding STIs
2. Advise what STI tests are required
Open-ended Question
D: Hi, my name is _____. I’ll be taking care of you today. How can I help you?
D: Congratulations on your new relationship!
Normalize & Confidentiality
D: Before we start, I will be discussing some sensitive topic about your sexual life, is that okay with you?
D: I’d like to reassure you that everything we discuss will be kept confidential
Counselling
- We have a special group of infections which are transmitted through sexual contact. Chlamydia, gonorrhea, HIV, syphilis are common infections in this group.
- Men who have sex with men are at a higher risk of getting sexually transmitted infections, and many of these STIs are asymptomatic which means that they don’t cause any symptoms, so some people are unaware that they have STIs.
1. Safe Sex
- The most important advice I can give you initially is to practice safe sex. Using a condom will significantly decrease the chance of getting STIs. Try to maintain a stable and regular partner. Try to avoid high risk sexual activity like having sex under the influence of drugs and alcohol, avoid casual partners and group sex.
2. Regular STI screening
- We recommend a complete STI screening to be done every 3 months for men who have sex with men.
- We are going to check for:
○ Chlamydia and Gonorrhea by taking swabs from the throat, the back passage, and a first pass urine, and send it for PCR test
○ HIV serology
○ Syphilis serology
○ Hepatitis B serology - HBS antigen
- I will do 2 extra tests, antibody testing for Hepatitis A and Hepatis B. These are viruses that cause inflammation in your liver, and men who have a sex with men have high risk of getting these viruses. But we can prevent it by vaccinating you against these. We will check your antibody level which shows us the level of immunity that you have against these viruses.
3. PrEP
- As HIV is the most serious sexually transmitted infection, and treating it is challenging, we offer HIV preexposure prophylaxis to all men who have sex with men. This is a medication that can prevent the transmission of the HIV in case you come in contact with it.
- The medication is a combination of two antiretrovirals: tenofovir and emtricitabine
- We have 2 types of PrEP:
○ Our preferred method is to have a daily, regular use of PrEP. This is more effective and has a higher chance of preventing HIV. But it is very important to have good compliance and you do not miss a tablet.
○ On-demand PrEP - you can take the medication 2 hours before having sex. This is not as effective as your regular daily PrEP. We prefer to do it for low risk MSM which means that you can delay sex for 2 hours and you engage in risky sexual activity less than 2 times/week.
- To be eligible to take PrEP:
○ We need to do an HIV test and get a negative result on your file before I prescribe it
○ I will need to check your kidney function, as kidney disease is a contraindication of this medication
○ PrEP is covered by Medicare (PBS - pharmaceutical benefit scheme) and be subsidized, but you have to agree to a 3-monthly STI screening
- Side effects of these medications: it can cause a bit of a headache, nausea, but it’s major side effect is it can affect your kidneys, that’s why it’s very important to check your kidney function before we start and repeat it every 6 months. You also have to avoid medications that affect your kidneys. Please tell your GP and pharmacist whenever you need to take a new medications, and avoid anti-inflammatories and painkillers like ibuprofen.
- 4 Rs
○ I will give you a factsheet about safe sex from family planning Victoria and melbourne sexual health clinic
○ I will review you regularly: every 3 months for STI screening, and every 6 months for the kidney function tests
○ And if we want to start pre-exposure prophylaxis and you’re eligible for it, I will also do a hepatitis C testing for you
○ Just in case you’ve missed your Gardasil vaccination, we can also do the HPV vaccine for you
our next patient is a 25 year old lady who has presented to your general practice for advice. She is starting a same sex relationship and is seeking advice.
Tasks:
Take history from the patient
Counsel the patient regarding her concerns
Concerns:
Any chance for STIs?
Do I need to use condoms?
She has had previous male partners
Open-ended Question
D: Hi, my name is _____. I’ll be taking care of you today. May I know your name? How can I help you today?
D: Congratulations on your new relationship! I’m so happy for you.
D: Is there any concern that you would like me to address today?
Normalize and Confidentiality
D: Before we start, I will be discussing some sensitive topic about your sexual life, is that okay with you?
D: I’d like to reassure you that everything we discuss will be kept confidential
Explore the Presenting Complaint: New Relationship
D: Can you tell me more about your new relationship?
D: Have you started having sexual activity?
Sexual History
D: Do you have an idea about what type of sexual activity you’ll be having like oral sex, use of toys?
D: Were you sexually active before this relationship?
D: Were your previous partners male or female?
D: Were you in a stable relationship?
D: Have you ever had multiple partners?
D: Were you practicing safe sex and using condoms?
D: What kind of sex were you having? Oral, vaginal or anal?
D: Have you ever been diagnosed with STIs before?
D: Have you ever had sex under the influence of drugs and alcohol?
Gynecological Health Check
D: When was your last menstrual period? Is it regular?
D: Are you upto date with your cervical screening test?
D: Have you had your Gardasil vaccination while you were in school?
D: Have you noticed any vaginal discharge?
D: Any rash, warts or skin lesions in your private parts?
Counselling
Congratulations again on your new relationship. Regarding your question, STIs are common in women who have sex with other women. However, the types of STIs that this group has are different with other groups. We have a higher risk of infection of bacterial vaginosis and trichomoniasis. Warts, candida, herpes can also happen due to skin to skin contact. There is a lower risk of other STIs like chlamydia, gonorrhea, HIV and syphilis.
Some STIs may not show symptoms and stay hidden, and this is why I can offer a full STI screening to both of you before you start sexual activity. You can discuss this with your partner and ask her to come see me and we’ll have a chat about it.
I can arrange for the following:
chlamydia and gonorrhea PCR. We can get a swab during a speculum exam, or you can do a self-collected swab, or we can use a first pass urine and send for testing
HIV serology
syphilis serology
Hepatitis B titers
Since you’re also due for your cervical screening test, we can also take the swab for that today.
Safe Sex advice
Avoid sex if you see any rash or discharge
Avoid high risk sexual activity like having sex under the influence of drugs and alcohol
You can use condoms or dental dams which are latex barriers that you can use during oral sex
If you’ll be using toys, you can use condoms and change it between partners, or have separate toys. Wash them thoroughly after use
If you’re using fingers, always wash your hands, keep your nails short
Other advice
Always keep upto date with your cervical screening test
Gardasil vaccination if not yet given
I can refer you to support groups like Rainbow Health, and they can provide you lots of materials and information about safe sex
