eMJA: Donovan et al, Gonorrhoea screening in general practice: perceived barriers and strategies to improve screening rates

Public Health

Gonorrhoea screening in general practice: perceived barriers and strategies to improve screening rates

Basil Donovan, Vickie Knight, Anna M McNulty,
Virginia Wynne-Markham and Michael R Kidd

MJA 2001; 175: 412-414

Abstract - Methods - Results - Discussion - Acknowledgements - Competing interests - References - Authors' details
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Abstract

Objective: To investigate perceived barriers to gonorrhoea screening in general practice and suggest strategies to overcome them.
Design: Questionnaire-based survey.
Setting and participants: All 47 general practitioners (GPs) authorised to prescribe subsidised HIV drugs under the Pharmaceutical Benefits Scheme in inner, eastern and northern Sydney.
Main outcome measures: Agreement on a five-point Likert scale with statements about attitudes and practices in relation to gonorrhoea screening of homosexually active men, and views on how testing rates could be increased.
Results: 32 GPs responded (68%). Perceived barriers to gonorrhoea testing included structural measures imposed by the Federal Government to limit pathology testing by GPs (the Medicare "three-test rule") (17 respondents agreed or strongly agreed), pressure from the Health Insurance Commission (HIC) to minimise pathology testing (15), concerns about confidentiality of notification procedures (8), clinical time pressure (8), and concerns about recriminations against HIV patients with gonorrhoea (6). Suggested measures to increase testing were education of gay men to request testing (25), relaxation of the three-test rule (25), easier tests (23), anonymous notification procedures, review of HIC policy on screening, and training about testing (21 each).
Conclusions: Sydney GPs with high HIV caseloads perceived structural barriers to gonorrhoea testing and supported a range of achievable strategies to overcome these. As the sustained epidemic of gonorrhoea in Sydney may be directly promoting HIV transmission, these strategies should be considered urgently.

Sydney is currently in the fourth year of an epidemic of gonorrhoea among homosexually active men, with over 1000 cases reported annually in the inner city.^1,2 This epidemic is of particular concern as gonorrhoea may be a marker of increased risk of HIV infection.³ Gonorrhoea also directly promotes HIV transmission,⁴ and treating gonorrhoea has been shown to reduce HIV levels in semen.⁵ Thus, these sustained high rates of gonococcal infection are likely to be leading to new, potentially preventable HIV infections.

Factors that may be contributing to the epidemic are:

increasing rates of unsafe sex among a subset of homosexually active men;^6,7
gonorrhoea outbreaks among gay men in other industrialised cities^7-9 that have links with Sydney;³
scaling down of the main public sexual health centre servicing the inner city;^2,3 and
limited gonorrhoea case-finding in the private sector.²

Most Australians diagnosed with sexually transmissible diseases (STDs) are managed in the private sector. Medicare, Australia's universal health insurance system, rebates or heavily subsidises patient services provided by the private sector. To minimise abuse of this system, Medicare imposes conditions, including:

rebating only three pathology tests ordered by a general practitioner (GP) on any one patient on any one day (the "three-test rule");
discouraging "screening" (testing without symptoms) of patients through Health Insurance Commission (HIC) advisers, who monitor and counsel GPs about their use of pathology and radiology services; and
not rebating STD testing of sex workers.

While urethral gonorrhoea usually causes symptoms in men, prompting them to seek treatment, anorectal infections have variable, often subtle, symptoms,^3,10 and pharyngeal gonorrhoea is asymptomatic.¹¹ Consequently, detection of anorectal and pharyngeal gonorrhoea depends on screening according to sexual risk history, contact tracing, and maintaining a low threshold for testing. The relative infrequency of diagnosis of these infections in general practice² suggests structural or cultural barriers to gonorrhoea screening of homosexually active men. Our study aimed to investigate these barriers and to seek solutions from a group of GPs with large numbers of patients at increased risk of gonorrhoea.

Methods

The study was conducted in October 1999. A one-page questionnaire was sent to all 47 GPs authorised to prescribe subsidised HIV drugs under the Pharmaceutical Benefits Scheme in inner, eastern and northern Sydney. This group was chosen because their practices were located at the centre of the gonorrhoea epidemic² and were presumed to contain substantial numbers of homosexually active men, and because HIV-infected men are at increased risk of anorectal gonorrhoea.³

The questionnaire comprised items enquiring about GPs' attitudes and practices in relation to screening homosexually active men for gonorrhoea, and their views on how STD testing rates could be increased. Questions were to be answered on a five-point Likert scale. All responses were kept anonymous. Most issues raised on the questionnaire were suggested at informal meetings with GPs with high HIV caseloads or during the pilot phase, when five such GPs were sent an earlier draft of the questionnaire for comment. Non-respondents were not prompted, as it was necessary to complete the study quickly, before commencement of a targeted community education program.

Results

Thirty-two of the 47 GPs (68%) returned the questionnaire. All disagreed that testing for gonorrhoea is "someone else's job", and 31 of the 32 disagreed with the suggestion that gonorrhoea is "trivial". Most respondents were aware that men at high risk of STDs who may have asymptomatic infections attended their practices and most felt competent to collect laboratory specimens.

Other results are shown in the Box. Interestingly, no respondents said they treated gonorrhoea empirically without testing to avoid notification, and few were embarrassed about gonorrhoea testing or thought it would offend patients. Barriers to gonorrhoea testing perceived by respondents included Medicare's three-test rule (17 respondents agreed or strongly agreed), pressure from the HIC to minimise pathology testing (15), concerns about confidentiality of notification procedures (8), clinical time pressure (8), concerns about recriminations against HIV patients with gonorrhoea (6), and a need for the patient to raise the issue of testing (5). One respondent reported having been directly advised against STD screening by an HIC adviser, who allegedly stated that such screening was the role of public clinics.

Respondents supported the following approaches to controlling gonorrhoea among homosexually active men: education to encourage gay men to ask for testing (25), relaxation of the three-test rule (25), easier gonorrhoea tests (23), anonymous STD notification procedures, review of the HIC policy on STD screening, and training about testing (21 each).

Discussion

The three-test pathology testing rule was the most common factor that respondents indicated was inhibiting their gonorrhoea screening: 25 of 32 respondents felt that reform was needed. A standard HIV monitoring visit includes determination of T-cell subsets, viral load and haematology and biochemistry profiles,¹² which automatically exhausts any Medicare rebate for pathology providers. The cost of investigating any concurrent medical conditions, such as hepatitis C or HIV-related symptoms, must then be absorbed by the pathology service. Adding screening tests for bacterial STD (gonorrhoea, chlamydia and syphilis), particularly if required for several patients a day, inevitably strains the relationship between the ordering doctor and the pathology service. When preliminary results of this survey were presented to a general meeting of the Sydney HIV GP Study Group several GPs commented that they were distorting their clinical practice — and thus delaying necessary STD screening — to minimise the effect of the three-test rule.

Clearly, policies intended to curb Medicare spending on pathology testing in general may have negative implications for STD control. The simplest solution might be to exempt testing for STDs from the three-test rule. As a precedent, an exemption has been justified for cervical cytology tests to promote screening.

Clinical time pressure limiting gonorrhoea testing was an issue for a quarter of respondents. Possible solutions include moderating STD screening intervals according to level of risk, and developing screening guidelines according to results of recent research into risk factors.³

Respondents strongly supported development of easier tests for gonorrhoea. Swabbing the throat, urethra and anorectum for gonorrhoea generates three specimens. Testing the anorectum and urine for chlamydia — another emerging problem among homosexually active men^8,13,14 — generates two more specimens. The reliability of gonorrhoea tests collected in general practice is unknown. There is considerable scope for research into streamlining and evaluating STD testing in general practice.

Few respondents were concerned about disease notification procedures and possible repercussions for their HIV patients. However, notification might be a disincentive for some patients or their doctors, and anonymous STD notification procedures were supported by most respondents.

Contact tracing was not seen as a major issue, perhaps because the identity of the source is very often not known to gay men with gonorrhoea. Nevertheless, general practice is not well structured for contact tracing, and support services could be enhanced.

Acknowledgements

This study was funded by the New South Wales Health Department, but the opinions expressed are not necessarily those of the Department. We thank Levinia Crooks (Australasian Society for HIV Medicine) for providing a list of authorised HIV drug prescribers, Paul Sweeney (Sydney Sexual Health Centre) for assistance with data handling, and the Sydney HIV GP Study Group for its involvement.

Competing interests

None declared.

References

New South Wales Health Department. Year in review: communicable disease surveillance, 1999. NSW Public Health Bull 2000; 11: 161-168.
Donovan B, Bodsworth NJ, McNulty A, et al. Increasing gonorrhoea reports — not only in London [letter]. Lancet 2000; 355: 1908.
Donovan B, Bodsworth NJ, Rohrsheim R, et al. Characteristics of homosexually active men with gonorrhoea during an epidemic. Int J STD AIDS 2001; 12: 437-443.
Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 73: 3-17.
Cohen MS, Hoffman IF, Royce RA, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1. Lancet 1997; 349: 1868-1873.
Van de Ven P, Prestage G, French J, et al. Increase in unprotected anal intercourse with casual partners among gay men in 1996-8. Aust N Z J Public Health 1998; 22: 814-818.
Page-Shafer KA, McFarland W, Kohn R, et al. Increases in unsafe sex and rectal gonorrhoea among men who have sex with men — San Francisco, California, 1994-1997. MMWR Morb Mortal Wkly Rep 1999; 48: 45-48.
Handsfield HH, Whittington WLH, Desmon S, et al. Resurgent bacterial sexually transmitted diseases among men who have sex with men — King County, Washington, 1997-1999. MMWR Morb Mortal Wkly Rep 1999; 48: 773-777.
Hughes G, Simms I, Rogers PA, et al. New cases seen at genitourinary medicine clinics: England 1997. Comm Dis Rep 1998; 8: S1-S11.
McNulty A. Anorectal gonorrhoea revisited. Venereology 1993; 4: 109-111.
Weisner PJ, Tronca E, Bonin P, et al. Clinical spectrum of pharyngeal gonococcal infection. N Engl J Med 1973; 288: 181-185.
Clinical Trials and Treatments Advisory Committee (CTTAC). Model of Care for HIV Infection in Adults. Canberra: Australian National Council on AIDS and Related Diseases, 1998.
Debattista J, Dwyer J, Orth D, et al. Community screening for Neisseria gonorrhoeae and Chlamydia trachomatis among patrons of sex-on-premises venues: two years later. Venereology 2000; 13: 105-109.
Bloch M, Delpech V, Austin D, et al. Screening for gonorrhoea and chlamydia in gay men in an inner city primary care practice. Presented at the Australasian Sexual Health Conference Jun 2000; Darwin, NT.

(Received 2 May, accepted 26 Jul 2001)

Authors' details

Sydney Sexual Health Centre, Sydney Hospital, Sydney, NSW.
Basil Donovan, MD, FACSHP, Director, and Clinical Professor, Department of Public Health and Community Medicine, University of Sydney, NSW;
Vickie Knight, RN, MHScEd, Clinical Nurse Consultant;
Anna M McNulty, MM, FACSHP, Clinical Senior Manager, and Nurse Consultant, School of Community Medicine, University of New South Wales, Sydney, NSW;
Virginia Wynne-Markham, Administrative Officer.

Department of General Practice, University of Sydney, Sydney, NSW.
Michael R Kidd, MD, FRACGP, Professor, and Head.

Reprints will not be available from the authors.
Correspondence: Professor B Donovan, Sydney Sexual Health Centre, Sydney Hospital, GPO Box 1614, Sydney, NSW 2001.
donovanbATsesahs.nsw.gov.au

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Responses of 32 general practitioners with high HIV caseloads to a questionnaire about gonorrhoea screening (in order of frequency of responses)

Questionnaire item	Strongly agree/ agree	No opinion	Strongly disagree/ disagree

(Please tick the box you feel is most appropriate)
Please comment on the following potential influences on your screening of homosexually active men for gonorrhoea
The 3-test pathology testing rule impedes my testing for gonorrhoea and other STDs	17	1	14
I feel pressure from the Health Insurance Commission about my pathology ordering practices	15	3	14
It is necessary to swab the throat, urethra and anus of every gay man who had sex >1 partner every 3 months*	9	5	16
I have concerns about the confidentiality of the notification procedure for gonorrhoea	8	5	19
Clinical time pressures prevent me from testing for gonorrhoea	8	1	23
I'm worried about recriminations against my HIV patients with gonorrhoea�	6	3	22
I rarely think of testing my patients for gonorrhoea	6	2	24
There are too many specimens to juggle	6	1	25
The patient needs to request gonorrhoea/STD testing	5	2	25
It would offend my patients if I suggested that they need testing�	3	2	26
I am too embarrassed to do anal swabs	1	2	29
I would usually know if my patients had gonorrhoea anyway	1	1	30
I treat gonorrhoea empirically without taking a swab to avoid confidentiality/notification issues	0	1	31

Which of the following do you believe would increase testing for gonorrhoea and other STDs
Gay men need to be educated to ask for regular STD testing	25	4	3
Relaxing of the 3-test rule (eg, excluding STD and HIV tests from formula)*	25	2	5
Easier pathology tests�	23	1	7
Anonymous STD notification procedure�	21	7	3
Review of Health Insurance Commission policy on frequency of STD pathology tests	21	8	3
Training or an update on gonorrhoea and STD testing�	21	4	6

STD=sexually transmissible disease. *Two general practitioners did not respond to this question. �One general practitioner did not respond to this question.

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