Testing for STIs - four case scenarios

Scenario 1: Young patient, under 25 years, attends surgery for a minor ailment.

Offering STI testing to young patients is good practice. A consultation for a minor ailment may provide time and opportunity to initiate a discussion about sexual health.

A simple non-judgmental non-threatening way of initiating the discussion might be to say something such as “...it is my usual practice to offer a sexual health check to all young people at this surgery. This does not always require an examination.”

For patients who decline examination, self collection may be appropriate. Women can perform a self taken lower vaginal swab and men can collect a first void urine for Chlamydia testing.

If the patient has symptoms, is at high risk of an STI, or the test returns a positive result, a full follow-up STI examination and testing is recommended.

Scenario 2: Patient requesting an STI check.

Often patients may request STI screening for reassurance that they do not unknowingly carry an STI. A patient may ask for this at the beginning of a new relationship, when deciding to no longer use condoms in a monogamous relationship, or for just a “check-up”.

A full sexual history and examination will help to determine risk and guide testing. This would typically include a smear, if appropriate, and swab (for women), or FVU (for males) for Chlamydia. A separate swab should be obtained for gonorrhoea and trichomonas. Serology testing for HIV, hepatitis B and C, and syphilis will be guided by findings in history and examination.

Scenario 3: Patient presenting within a day or two after unsafe sex.

Sometimes patients may present worried about recent unsafe sex. Due to the incubation times of most pathogens, there is limited diagnostic value in performing any tests until at least about 2 weeks after the potential exposure. In the meantime, this provides a good opportunity to discuss good sexual health practice, contraception, arrangements for follow-up and empirical treatment if appropriate.

Scenario 4: Patient presenting who practices unsafe sex - with additional risk factors.

A detailed sexual health history may highlight any additional risk factors. These may include sexual activity such as MSM, having multiple sexual partners, previous STI, sex with a sex worker or person from a high risk country or an IV drug user.

The findings in history and examination would influence sites of sampling (eg anus, pharynx) and the range of swabs and serology tests performed. It is worth remembering that in high risk groups, the presence of more than one pathogen is not uncommon, and that certain STIs may be more prevalent (eg among MSM). Those that continue with unsafe sexual practices should be encouraged to have frequent sexual health checks.