THEME: STIs

The sexually transmitted

infection ‘check up’
Screening for STIs in general practice
Linda Dayan,
Catriona Ooi

BACKGROUND Many sexually transmitted infections (STIs) and blood borne viruses (BBV)
such as HIV are asymptomatic. Early detection is important for minimising associated risks.
With appropriate treatment and management (including contact tracing) it is possible to
substantially reduce morbidity as well as transmission to sexual partners and the neonate.
OBJECTIVE This paper outlines which tests should be administered to otherwise ‘well’
individuals. It also examines the questions of when, why and how to respond to requests
for an STI ‘screen’ or ‘check up’.
DISCUSSION Testing and screening for asymptomatic STIs and BBV are important, Linda Dayan,
especially in situations where proven interventions can decrease morbidity and BMedSc, MBBS,
transmission. Screening for STIs also provides the opportunity in a one-on-one DipRACOG, MM
consultation for health promotion. Sexually transmitted infection testing can also initiate (VenSci), FACSHP,
MRCMA, is Director,
a conversation about ‘safer sex’ and may help address other concerns patients may have. Sexual Health
Services, Northern
Sydney Health,
New South Wales.
‘S creening’ is defined as testing carried out
among apparently well people to identify
those at an increased risk of a disease or disorder.1
individual concerns, public health and cost issues
need to be balanced when considering any screen-
ing tests.
Catriona Ooi, MBBS,
BSc (Med), is a
Screening for bacterial sexually transmitted infec- registrar, Department
tions (STIs) offers opportunities for early Responding to the request of Sexual Health,
for a sexual health ‘check up’ Royal North Shore
intervention and treatment and has been shown to and Manly Hospitals,
reduce rates of transmission2 thereby decreasing Asymptomatic patients may request an ‘STI check New South Wales.
morbidity. up’ after entering a new sexual relationship, before
Screening can be based on selective criteria for embarking on unprotected sex. Couples are
those at higher risk or routinely offered to every- encouraged to get ‘tested’ before ceasing condom
one. The cost effectiveness of each approach use, and efforts should be made to ensure that both
depends on the prevalence of infection within the partners are tested.
community or group being ‘screened’, the type of Patients may also present requesting testing
test used, its specificity and sensitivity, the cost of because they are unwilling to divulge other risks,
the test and the availability of an appropriate inter- may be symptomatic or worried. Direct question-
vention to minimise morbidity and/or mortality.3 ing about specific symptoms should form part of
Screening to detect asymptomatic infection should the history.
only occur if it is possible to decrease transmission, Patient concern and request for a ‘check up’
morbidity or mortality through intervention. may be a surrogate marker for other health issues
Detection should not cause physical or psychologi- such as erectile dysfunction.4 A request for an HIV
cal harm to the patient. test may reveal concerns about partner fidelity,
Medicolegal issues may also need to be consid- sexuality issues or a sexual assault.5 Anyone who
ered when screening for STIs. This, combined with has experienced sexual contact may present for a

Reprinted from Australian Family Physician Vol. 32, No. 5, May 2003 • 297
n The sexually transmitted infection ‘check up’ – screening for STIs in general practice

Table 1. Our recommendation for STI and BBV screening Table 2. Suggested open ended
questions for taking a sexual history
Screening asymptomatic individuals at risk through noncommercial sexual
activity • Why do you think you have been at risk of STIs
• Anyone who asks for a test or HIV?
• Contact of anyone with an STI • Which STIs are you particularly concerned about?
• Young sexually active people under 25 years of age (chlamydia especially) • What do you think I need to know about your
• Unprotected sex (especially overseas country of higher HIV risk) sexual practises to ensure that I order the best
tests?
• Multipartnered individuals
• What do you do to protect yourself against HIV
• Recent change in sexual partner
infection and other STIs?
Regular or periodic STI testing for those at higher risk due to occupational
• In what situations would you be less likely to
risk/sexual risk and/or public health reasons
use condoms?
• Commercial sex workers (regular screening for STIs to ensure safety to and
• Tell me about your use of condoms, for anal
from clients)
sex, vaginal sex, oral sex?
• Men having sex with other men (multisite testing) (especially multisite
gonorrhoea and chlamydia) (Table 5*)
• Health professionals at risk of needlestick injury (HIV, HCV, HBV [if not
vaccinated])
more about the type of check up you want?’ or
Other groups to be considered
‘What do you expect the check up to reveal?’ may
• Pregnant women (especially HIV, syphillis, hepatitis B and C, and
elicit useful information about the reasons for pre-
chlamydia/gonorrhoea, +/– BV)
sentation (Table 2). Some patients may be
• Pregnant women referred for termination of pregnancy (TOP) (BV,
chlamydia and gonorrhoea, important to decrease risks of pelvic reluctant to disclose information unless asked
inflammatory disease post-TOP) direct closed questions about their sexual activity
• HIV positive individuals (concomitant infections have been shown to (Table 3).
increase risk of HIV transmission) Initially, the patient interview should establish
the reason for presentation, identify risks of infec-
tion and clarify any misconceptions the patient may
have. The sexual history and risk assessment may
reveal sexual practices or issues that will focus the
sexual health screen and requests for testing consultation accordingly; for example, if the patient
should not be dismissed, regardless of risk. Sexual divulges that they are a commercial sex worker or a
history and risk assessment are important to tailor homosexual man more regular and multisite STI
testing, counselling and education (Table 1). screening would be required (Table 5).

STI risk assessment Screening for STIs in general

An accurate history should aid the practitioner in
practice – what investigations
and why?
assessing the likelihood of a positive result, as well
as targeting patient education and providing essen- Clinical time pressures, concerns about confiden-
tial health promotion information (Table 2, 3). The tiality and structural barriers imposed by the
limitations of the tests themselves, incubation and federal government to limit pathology testing by
window periods of the tests should also be dis- general practitioners may make comprehensive
cussed (Table 4). screening for STIs difficult.7 Testing over two con-
Consultation in a private, nonthreatening, non- sultations may make the process more feasible.
judgmental forum may help clarify reasons for
presentation. Use language that you feel comfort- HIV
able with and that the patient understands. It is Despite human immunodeficiency virus (HIV)
also important to explain to the patient why you sero prevalence in Australia estimated at
are asking certain questions: ‘In order to establish 66:100.000,8 the consequences of undiagnosed and
your level of risk of HIV, I will need to ask you untreated HIV infection are fatal. Until a decade
some personal and private questions’. ago little could be offered to HIV positive patients.
Open ended question such as: ‘Can you tell me However, recent years have seen a paradigm shift
298 • Reprinted from Australian Family Physician Vol. 32, No. 5, May 2003
 The sexually transmitted infection ‘check up’ – screening for STIs in general practice n

Table 3. Suggested closed questions Table 4. Which test to use for STI screening and window
for taking a sexual history periods of common STIs

Present sexual history Screening test Window Comment

• Are you in a sexual relationship at the period
moment? With a male or female partner? HIV HIV Ab/Ag 6–12 weeks Newer tests combine HIV
• When did you last have sex? Was that with a antigen with HIV antibody
male or female partner? Casual or regular Syphilis EIA 2–12 weeks Repeat serology for those
partner? or with suspected exposure
• Have you had any other partners? While in this RPR/VDRL + 3–12 weeks
relationship? TPPA/TPHA
• Have you had a change in partner? Hepatitis B HepB coreAb 4–24 weeks Past exposure
• Do you have vaginal sex? oral sex? anal sex? HepB sAg 4–8 weeks Carrier status/recent infection
HepB sAb Past vaccination
• What percentage of the time do you use
condoms for vaginal sex? anal sex? oral sex? Hepatitis C HepC Ab 2–26 weeks
Past sexual history Chlamydia First catch urine 2–7 days Men and women
PCR/LCR
• How many sexual partners you have had in the
Cervical swab In women: sensitivity of cervical
past?
PCR/LCR swab slightly greater than
• Without condoms? (do not say ‘protection’, ie. urine test
it could mean ‘the oral contraceptive pill’)
Gonorrhoea First catch urine 24 hours Men (beware gonorrhoea
• Do you have sex with men, women or both? Gonorrhoea PCR false positives – confirm
• Have you ever had sex with someone of the culture/PCR with culture)
same sex? Cervical culture/ Women (beware NG PCR/LCR
Overseas risk (as other countries have different PCR false positives – confirm with
rates of HIV infection) culture)
• Have you ever had sex with someone from
overseas?
• Where were they from?
Nonconsensual sex
• Has anyone forced you to have sex that you
Table 5. Testing recommendations for
didn’t want to have?
men who have had any sex with other
• Have you had any unwanted sexual contact?
men in the previous 12 months*
Commercial sex worker (CSW) and/or client of a
CSW
The following tests should be offered at least
• Have you ever been paid for sex? once a year:
• Have you ever paid for sex? Serology
Sexual dysfunction • HIV serology
• Do you have any problems with sexual • Syphilis serology
intercourse?
• Hepatitis A serology – immunise if negative
• Have you ever discussed these with anyone?
• Hepatitis B serology – immunise if negative
Introducing hepatitis C
Swab tests
‘Your liver tests are a little raised, sometimes this
• Pharyngeal: gonorrhoea culture
can be caused by hepatitis viruses.
I would like to ask you some personal questions • Anal: gonorrhoea culture or PCR
so I can establish what risks you may have of chlamydia PCR
hepatitis C infection’: Urine tests
• Have you ever injected drugs? • First catch urine: chlamydia PCR, gonorrhoea
• Have you ever had a tattoo that may have culture or PCR
been done in an unsterile way?
• Did you have a blood transfusion before 1990?
*Guidelines developed by the Australian College of
Sexual Health Physicians. [Link]

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 The sexually transmitted infection ‘check up’ – screening for STIs in general practice n

The full STI check up involves blood and/or genital and urine tests

BLOOD TESTS

The routine 'STI' blood tests check for infection with:

o HIV (human immunodeficiency virus)
o Hepatitis B
o Syphilis
HIV and hepatitis B are viral infections that may be transmitted in semen and cervical/
vaginal secretions during vaginal or anal sex where no condom has been used. It may take
up to 3 months for any of these infections to show in the blood tests.
If there have been blood-to-blood risks, then we may also test for:
o Hepatitis C (which is not usually transmitted sexually)
In some cases, other infections may also be transmitted sexually and can be tested for by blood,
such as:
o Hepatitis A

GENITAL AND URINE TESTS

An STI 'screen' or 'check up' will also involve tests for the following bacteria:
o Chlamydia
o Gonorrhoea
Bacterial infections are treatable with antibiotics amd may be harmful if left untreated.
Up to 80% of women and 50% of men with chlamydia have noticed nothing unusual, and do not
know they are infected.
The ONLY way to know is to get tested
Women may also have vaginal swab tests if they notice an unusual vaginal discharge or
discomfort. Although trichomonas is sexually transmitted, bacterial vaginosis and candida are
not sexually transmitted infections and all are easily treated.
o Bacterial vaginosis (this was called gardnerella)
o Candida (this may also be called thrush)
o Trichomonas (this is a sexually transmitted infection)

OTHER COMMON VIRAL STIs

Subclinical (invisible) genital wart virus infection is extremely common and may be found in
up to 50%* of the population. We cannot test for the invisible (subclinical) infection, but if
obvious warts are present, they can be easily diagnosed and treated.
The invisible wart virus is also associated with Pap smear changes, and as wart virus is
so common it is recommended that EVERY WOMAN HAS REGULAR PAP SMEARS every
two years.
Genital herpes virus infection is also very common and is found in up to 30% of the population.
75–80% of those who are infected do not know that they have been exposed,
and have no symptoms (that is they have invisible infection). Good medication is available to
manage symptoms or sores if they are present, and to reduce the frequency of recurrences. The
most accurate tests for herpes is the swab test when there are sores present. The genital herpes
virus may be transmitted even if there are no sores present.
In general, an STI check up does NOT test for (invisible) infection with either the genital
wart or genital herpes viruses. Both infections are transmitted by skin-to-skin contact and
are very common.

*This figure can vary depending on the population tested and type of test.
!

Figure 1. The sexually transmitted infection (STI) check up

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n The sexually transmitted infection ‘check up’ – screening for STIs in general practice

in the management of HIV through the use of HIV had a blood transfusion before 1990 or who were
antiviral agents. These medications have signifi- born in a country of high hepatitis C prevalence
cantly increased life expectancy and reduced (eg. Egypt).
mother-to-child transmission.9
With the significant morbidity and mortality of Chlamydia
HIV combined with the ease and availability of Chlamydia is the most commonly notifiable bacter-
good diagnostic testing, an HIV antibody test ial infection in Australia,12 and recent studies have
should be an obligatory part of the STI check up. recommended that all young adults under 25 years
To omit an HIV test or recommend against it of age who are sexually active should be screened
could be seen to be medically indefensible. Should for infection irrespective of sexual history.13
the patient decline an offered HIV test, this should Chlamydia is asymptomatic in up to 50% of
be documented clearly in the notes. The impor- men and 80% of women.14 It is easily detected with
tance of the three month window period should noninvasive nucleic acid testing (PCR/LCR) from
also be carefully discussed. urine and is easily treated. It may have serious con-
sequences such as pelvic inflammatory disease
Syphilis resulting in infertility and ectopic pregnancy if left
Syphilis testing should always form part of the ‘STI undiagnosed.
screen’ as it is a treatable condition with serious Modelling shows that when the sero prevalence
associated morbidity and mortality, including peri- within a community reaches 3%, screening is cost
natal mortality. Routine tests for syphilis are effective,15 and in Australia rates as high as 27%
inexpensive and accurate. Recent years have seen have been reported in one adolescent population.16
an increase of syphilis among homosexual men in Detection rates may be increased if young women
western countries,10 in parallel with rises in former are offered the option of urine testing rather than
soviet countries and China. insisting on a cervical test17 due to a higher yield of
samples. Screening in young men, while perceived
Hepatitis viruses: A, B, C as not as important, should be strongly
Hepatitis A may be sexually acquired by the oro- encouraged.18
faecal route, via oro-anal or oral sex. Recent
outbreaks of hepatitis A have occurred in homo- Gonorrhoea
sexual men in the western world. As this viral Following a worldwide trend, the rate of neisseria
infection has significant morbidity and is pre- gonorrhoea (NG) infections has increased substan-
ventable through vaccination, all men having sex tially in the homosexual population.19 Other groups
with other men should be tested and offered vacci- who may be at risk include some indigenous popu-
nation (Table 5). lations living in rural areas and those having
Hepatitis B may have very serious conse- unprotected sex while overseas.
quences, although the majority of adults acquiring Reservoirs of asymptomatic infection provide
the infection as an adult will overcome the virus. the key for screening, as men acquiring the infection
Despite some treatments available for managing in the urethra are often symptomatic. As the infec-
the infection, hepatitis B remains highly infectious tion may remain asymptomatic and self limited in
and is preventable through vaccination. Hepatitis the throat and rectum, multisite swabs should be
B should be ordered in a routine STI screen and offered to men who have sex with other men.
vaccination offered to ‘at risk’ patients. As NG may be asymptomatic in up to 80% of
Hepatitis C (HCV) is primarily transmitted women a routine STI screen for infection should
through blood-to-blood contact. Risk of HCV include a cervical culture for NG. Noninvasive
transmission via sexual contact is low, estimated at nucleic acid tests (PCR/LCR) for NG in first catch
up to 0.6% per year in monogamous relationships urine specimens can be used for screening men, but
and up to 1.8% per year in those with multiple positive results must always be confirmed with
partners.11 The STI check up, may be an appropri- culture due the high rate of false positive tests.
ate time to perform a hepatitis C test, in those who These tests have not yet been fully evaluated for use
may have been exposed. These include people with in women in areas of low NG prevalence, however,
a history of injecting drug use, prisoners, those who they may play a significant role in the future.
302 • Reprinted from Australian Family Physician Vol. 32, No. 5, May 2003
The sexually transmitted infection ‘check up’ – screening for STIs in general practice n

Asymptomatic HPV infection detect trichomonas through ‘wet mount’ but the
Human papillomavirus (HPV) is a very common sensitivity of such tests is at best 30–70%.
infection with most HPV infections remaining
asymptomatic. It is estimated that over 50% of sex- Conclusion
ually active adults have been infected at some Screening for STIs should include infections that
point in their lives.20 Condoms provide no protec- are of public health importance, that have serious
tion against HPV infection.21 Several HPV virus consequences if left untreated, and for which there
strains have been associated with precancerous are proven interventions to reduce morbidity.
cervical changes, and screening for cervical abnor- In some groups additional tests or periodic screen-
malities through Pap smears have shown to reduce ing may be appropriate.
rates of cervical cancer in western countries. At a minimum, the STI screen involves blood
tests for HIV, hepatitis B and syphilis, and swabs
Asymptomatic HSV infection or PCR/LCR urine tests for chlamydia and gonor-
Most infections with herpes simplex virus (HSV) rhoea. Depending on risk assessment, tests for
are asymptomatic with up to 80% of infections hepatitis A and hepatitis C may also be considered.
unrecognised and undiagnosed. HSV-2 is common Patient handouts (Figure 1, Resources) can be
(15–30%) and HSV-1 infection, usually acquired useful to give your patients so they are aware of
orally before the age of 15 years, is very common what tests have been conducted. A request for an
(75–80%). STI screen may mask other issues, and further clar-
Herpes simplex virus serology tests are now ification may be required. Should the GP feel
commercially available, however, these tests are uncomfortable discussing sexually related issues,
not as specific or sensitive as tests used for then referral to a sexual health centre would be
research, and false positive and negative results are appropriate.
common. Herpes simplex virus serology is not site
or symptom specific and as such, will not confirm a SUMMARY OF
genital lesion to be a herpes infection. IMPORTANT POINTS
Patients are increasingly requesting HSV serol-
ogy as part of a check up, however, testing for
• Screen all sexually active young people under
HSV serology has the potential for psychological
25 years of age for chlamydia.
harm with little positive effect. 22 Consider a
• Do not refuse a persistent request for an HIV
common scenario where a couple present for serol- test or STI screen. The patient may not be
ogy testing. One has HSV-2 and the other is telling you everything.
apparently not infected. It is important to consider • Urine testing is okay for chlamydia PCR in
how the result will affect the partner. If negative, women, if they are asymptomatic and do not
there are very limited measures for protection. need a speculum examination for another
Oral antiviral medications are not licensed for sup- reason (eg. Pap smear).
pression and at best decrease transmission by up to • A request for an HIV test should alert the GP
to the possibility of a full STI check up.
50%. Condoms may provide some protection for
• Screen pregnant women for HIV, hepatitis B,
women23 but not for men and vaccines are unavail-
syphilis, chlamydia and gonorrhoea to prevent
able. A positive test may require disclosure to a neonatal infection.
new partner with little intervention in a totally • Before termination of pregnancy, test for BV,
asymptomatic individual. chlamydia and gonorrhoea to prevent pelvic
While the use of HSV serology as a screening inflammatory disease.
tool continues to be debated we would not recom- • Unprotected sex while travelling overseas is a
mend routine screening for HSV infection. big risk for HIV and other STIs.
• Screen everyone who has had unprotected
Trichomonas sex overseas in countries of higher HIV and
STI prevalence, such as Africa, Asia, eastern
Trichomonas is the forgotten STI, and while the Europe and South America.
infection is more common in rural Australia, sensi-
tive and specific screening tests are not yet
commercially available. High vaginal swabs may Conflict of interest: none declared.
Reprinted from Australian Family Physician Vol. 32, No. 5, May 2003 • 303
n The sexually transmitted infection ‘check up’ – screening for STIs in general practice

Further Reading early syphilis: Cases from North Manchester General

Hospital, UK. Sex Transm Infect 2001;77:311–313.
1. Ooi C, Dayan L. Syphillis diagnosis and management 11. Terrault N A. Sexual activity as a risk factor for
in general practice. Aust Fam Physician 2002; hepatitis C. Hepatology 2002; 36:S99–S105.
31(7):629–634. 12. National Notifiable Diseases Surveillance System.
2. Ooi C, Dayan L. Genital herpes: An approach for Communicable Diseases: Australia. Communicable
general practitioners in Australia. Aust Fam Physician Diseases Network Australia, 2002.
2002; 31(9):825–831. 13. Heal C, Jones B, Veitch C, et al. Screening for
chlamydia in general practice. Aust Fam Physician
Resources 2002; 31(8):779–782.
14. Gaydos C A, Howell M R, Pare B, et al. Chlamydia
General STI information: [Link] trachomatis infections in female military recruits. N
Treatment guidelines and handouts for patients: Engl J Med 1998; 3339:739–744.
[Link]/std/treatment 15. Honey E, Augood C, Templton A, et al. Cost effec-
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Patient information in different languages:
Review of published studies. Sex trans Infect 2002;
[Link] 78(6):406–412.
Genital herpes information for doctors: 16. Quinlivan J A, Petersen R W, Guririn L C. High
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Provider willingness to screen all sexually active
For patients: [Link]
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[Link] 19. Donovan B, Bodsworth N, Rohrsheim R, et al.
Hepatitis C information: [Link] Increasing gonorrhoea reports: Not only in London.
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304 • Reprinted from Australian Family Physician Vol. 32, No. 5, May 2003