Key Points

• Multiplex diagnostic assays are being used by online and private providers to test inappropriately for some organisms
• Some providers offer treatment regimens which are inconsistent with national recommendations for first line therapy
• BASHH recommends that all STI service providers follow BASHH national clinical guidance for STI testing and offer first line treatment to all patients with an STI where possible

 

Background

Rising demand for accessible sexually transmitted infection (STI) services along with significant recent advances in molecular diagnostic capabilities, has led to a huge range of online providers in the UK delivering STI testing and treatment.  However, there is marked variation in the quality of these services. The public can access consultations through private service providers or online testing sites which sometimes give incorrect advice and at considerable cost.  As these sites may be linked to commercial providers of NHS online services, the “badging” of services suggests that they are NHS-and CQC-approved, and this is misleading.

 

Aim

The Bacterial Special Interest Group is a subgroup of The British Association for Sexual Health and HIV (BASHH), with a focus on promoting the highest standards in the management of bacterial STIs. The Group wishes to alert the relevant regulatory and advisory bodies to the testing and treatment practices of some STI service providers which are inconsistent with national guidance.

 

Testing

There has been a recent rapid increase in the number of available commercial multiplex assays which test for a variety of organisms using one specimen. The use of these multiplex assays is inappropriate for the following reasons:

• Testing for organisms of dubious significance, e.g. Ureaplasma parvum and Mycoplasma hominis
• Testing where not indicated, e.g. screening for genitalium rather than testing only in specific situations, is confusing and frustrating for patients who then attend sexual health clinics expecting to receive treatment.
• Inappropriate specimens are being used to test for certain infections e.g. urine sample for pallidum
• Most assays are CE-marked, which is easily achievable, but demonstrate poor sensitivity and specificity or have not been adequately validated

 

Treatment

Many on-line STI service providers are not offering first-line treatment options in line with national clinical guidelines to patients with confirmed STI e.g. offering oral cefixime/azithromycin for N. gonorrhoeae instead of signposting patients where possible to sexual health clinics for intramuscular injection of ceftriaxone; providing oral azithromycin, often at incorrect dose, instead of doxycycline because the duration of treatment is shorter.

Antimicrobial resistance

BASHH is concerned that testing and treatment practice that deviates from national clinical guidelines contributes to the rising problem of antimicrobial resistance, especially with respect to N. gonorrhoeae and M. genitalium.

 

Recommendations

Whilst accessibility to STI testing via online providers has grown in recent years, healthcare professionals and the public should be aware that many existing online services are not inspected and monitored by national regulatory bodies and therefore do not meet the standards expected by BASHH.

• All services offering STI testing and treatment to the public should be inspected and assessed on their performance in relation to BASHH guidance and standards
• All STI service providers should be able to demonstrate accreditation by a relevant regulatory body and the public should be alerted to the importance of using only reputable online sites for testing

 

 

Dr. Suneeta Soni, Consultant in Sexual Health and HIV

on behalf of the Bacterial Special Interest Group for BASHH

 

 

References

Taylor-Robinson D, Horner P, Pallecaros A. Understanding the terms we use: support for using ‘sexually shared microbiota’ (SSM). International Journal of STD & AIDS. 2020;31(2):183-185. doi:10.1177/0956462419885780

 Fifer H, Saunders J, Soni S, Sadiq ST, FitzGerald M. 2018 UK national guideline for the management of infection with Neisseria gonorrhoeae. International Journal of STD & AIDS. 2020;31(1):4-15. doi:10.1177/0956462419886775

Dragovic B, Nwokolo N. Update on the treatment of Chlamydia trachomatis infection https://www.bashhguidelines.org/media/1191/update-on-the-treatment-of-chlamydia-trachomatis-infection-final-16-9-18.pdf