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Sex Transm Infect. 2007 April; 83(2): 171–172.
PMCID: PMC2598613

NICE guidance on one‐to‐one interventions to reduce sexually transmitted infections and under‐18 conceptions: a view from general practice

Health promotion is a cornerstone of general practice.1 Issues including smoking, diet, alcohol and exercise are often raised with patients. However, given the restrictions of the 10 minute consultation, any intervention is brief. At best, it is reinforced with written information or referral. How will the new NICE recommendations on reducing STIs and teenage pregancies2 influence those working in general practice?

Are the recommendations appropriate to general practice?

There are five recommendations relevant to doctors and nurses working in primary care. To be effective these need to apply to all practices, not just the select few providing gold‐plated specialist sexual health services.

Recommendations 1 and 2 relate to counselling to reduce risky sexual behaviour. General practitioners (GPs) have little time to identify individuals at high risk and arrange sexual health counselling. Even if they did, it is unlikely young people would attend. Many practices do provide brief opportunistic sexual health promotion. This might include providing contraception, condoms and leaflets. Some practices are also involved in the National Chlamydia Screening Programme (NCSP). Primary care‐based health professionals might become more enthusiastic about sexual health counselling and condom promotion if they were aware that a more intensive intervention has been shown to prevent 9 STIs per 100 teenagers counselled.1,3 However, very few practices will have personnel trained in sexual health counselling who can provide “structured session(s) lasting 15–20 minutes”. Although such an intensive intervention is unrealistic in most general practices, this might be feasible by referral to youth services.

Recommendation 3 concerns partner notification. Because about half of young people referred to a genitourinary clinic fail to attend, it is vital that GPs and practice nurses who test for STIs undertake partner notification themselves. In one study, practice‐based partner notification by trained nurses, with telephone follow‐up by health advisers, was at least as effective as referral to a genitourinary medicine clinic for patients with chlamydia infection.4 If the partner is also registered with the practice, providing testing and treatment is relatively simple. Usually this is not the case, so doctors and nurses working in general practice need to be made aware of new evidence on the effectiveness of patient‐delivered partner therapy backed up by an information leaflet.5 For example, the index patient could be prescribed a double dose of azithromycin 1 g immediately (to which most gonorrhoea is also sensitive) so that both partners are treated. Although GPs are usually reluctant to prescribe for someone they have not seen and who is not their patient, many will feel the benefits outweigh the risks.

Recommendation 4 relates to primary care trusts (PCTs). These are responsible for genitourinary medicine clinics and for community‐based sexual and reproductive health clinics that offer contraception and some STI screening. Although there are exceptions,6 funding is often inadequate, and few outreach clinics are computerised. The NCSP provides a few community health advisers who can help GPs with treatment and partner notification, but PCTs are unlikely to have resources for new posts.

Recommendation 5 concerns sexual health advice for vulnerable young people aged under 18, especially contraception and the benefits of long‐acting reversible contraceptives. GPs and practice nurses do care for these young people when they attend. Many practices offer sexual health advice, condoms, contraception and STI testing to sexually active teenagers. However, this is a challenging client group who may not return for follow‐up appointments. They are more likely to access Brook Young People's Clinics and other youth counselling and sexual health services where available. Better funding and support for these services would probably be highly cost‐effective.

Will these guidelines affect the sexual health work of GPs?

Doctors and nurses working in general practices are drowning under a flood of guidelines. They receive recommendations from NICE on a wide range of topics every few weeks. Thus, publishing and distributing these new sexual health guidelines is unlikely to influence GPs who do not want to or cannot do more sexual health work. We believe there are three main messages for primary care:

  1. Opportunistic sexual health promotion such as brief counselling can reduce the incidence of STIs.
  2. Practice‐based partner notification using patient‐delivered therapy is effective.
  3. Long‐acting reversible contraceptives should be promoted in high‐risk sexually active adolescent women.

The introduction of the Quality and Outcomes Framework for management of chronic diseases shows that financial incentives can change what GPs do. This powerful lever is currently under‐represented in the sexual health field. To encourage implementation and ownership by those working in general practice, the new NICE guidelines need to be summarised on half a page of A4 and reinforced by practice‐based educational interventions.7

Footnotes

Funding: Dr Oakeshott receives research funding from the BUPA Foundation.

Competing interests: none declared

References

1. Reitmeijer C A. Risk reduction counseling for prevention of sexually transmitted infections: how it works and how it can be made to work. Sex Transm Infect 2007. 832–9.9 [PMC free article] [PubMed]
2. National Institute for Health and Clinical Excellence Public Health Intervention Guidance PHI003. Preventing sexually transmitted infections and reducing under‐18 conceptions: Guidance, 27 February 2007. http://nice.org.uk/page.aspx?o = 410627 Accessed 5 March 2007
3. Ward H. One to one counseling for STI prevention: not so much whether as how. Sex Transm Infect 2007. 831 [PMC free article] [PubMed]
4. Low N, McCarthy A, Roberts T E. et al Partner notification of chlamydia infection in primary care: randomized controlled trial and analysis of resource use. BMJ 2006. 33214–19.19 [PMC free article] [PubMed]
5. Trelle S, Shang A, Nartey L. et al Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review. BMJ 2007. 334354–357.357 [PMC free article] [PubMed]
6. Lambeth and Southark Sexual Health Website http://www.mysexualhealth.org.uk
7. Oakeshott P, Kerry S. Development of clinical guidelines. Lancet 1999. 353412 [PubMed]

Articles from Sexually Transmitted Infections are provided here courtesy of BMJ Publishing Group