Taking Jacinta’s history
A non-judgemental attitude and environment will maximise patient disclosures on sexual matters1. Consider asking questions such as:
- When was your last normal menstrual period?
- Do you have any intermenstrual bleeding?
- Do you have painful periods?
- Are you sexually active? If so:
- What are the genders of the people you have sex with?
- Prompt further if required.
How do you have sex? Vaginal sex/oral sex/anal sex? - How often do you use condoms?
- Do you experience any pain during sex?
- How many partners have you had in the past three months?
- Have you had a cervical screening test? When did you have it? What was the result?
- Have you previously had an STI?
- When was your last STI screening test
- What is the nature of the discharge? Colour? Amount? Odour?
- Have you had any dysuria/urinary frequency?
- Have you had any vulval itching or soreness? Or any skin changes around your vagina?
- Do you have fever/sweats?
- What contraception do you use?
- Have you had any recent instrumentation of the uterus (i.e. IUD insertion, hysteroscopy, D&C)?
View guidelines
View guidelinesTypical sexual health examination
Vital signs
Full ward test (FWT) of urine
Urine bhCG
Abdominal examination
Speculum examination to visualise cervix and discharge
Swabs: both vaginal (endocervical and high vaginal) and urethral
Bimanual examination
Prevalence of STIs in Australia
While the true prevalence of STIs in the community is not known (as most people at risk have not been tested), it is known that STIs are very common particularly in young people (under 30).
Other populations at higher risk of STIs are:
- People who have unprotected sex with casual partners
- Men who have unprotected anal sex with men
- Aboriginal and Torres Strait Islander people
- People who have unprotected sex overseas
- People who inject drugs
In the Northern Territory in 2011, chlamydia rates were three times the average Australian rate and gonorrhoea rates were 16 times the Australian rate.
Syphilis, which had been uncommon in Australian cities until recently, has re-emerged as a major sexually transmissible infection among men who have sex with men (MSM).
View websiteBacterial and viral STIs
Bacterial STIs
- Chlamydia trachomatis (most common bacterial STI)
- Gonorrhoea
- Syphilis
- Lymphogranuloma venereum (LGV, caused by serovars L1-L3 chlamydia trachomatis)
- Mycoplasma genitalium
Viral STIs
- Human papillomavirus (HPV)
- Herpes simplex virus (Genital warts)
- Human immunodeficiency virus (HIV)
- Hepatitis B
In rare instances:
- Hepatitis A can be spread by anal contact with an infected person
- Hepatitis C can be spread during sexual activity if there is blood to blood contact
Taking swabs
The following swabs are standard:
- High Vaginal Swab (HVS):
- Microscopy, culture and sensitivity (MCS)
- HVS is laboratory specific, however the swab smeared onto a glass slide is ideal
- Endocervical swab:
- Microscopy, culture and sensitivity (MCS)
- Chlamydia PCR (polymerase chain reaction) +/- gonorrhoea PCR +/- trichomonas PCR
- It is important to ask for gonorrhea culture so that sensitivities can be monitored
MCS swabs: Use a plain swab in Amies Transport Medium for MCS swabs from any site (different pathology providers could have swabs of different colours). This swab will also test for viral PCR including herpes.
Chlamydia/Gonorrhoea Roche swabs: Swabs for Chlamydia & Gonorrhoea PCR need to be taken with a specific swab. This cannot be used for other PCR collections. Use the larger swab for the throat and rectal collections. Use the larger swab to remove mucous and discard, follow with the small swab for endocervical collection. This test can also be done on CST thin prep collection
Other tests
- Bloods:
- FBE (full blood examination)
- Take blood cultures if patient is febrile (>38.5°C)
- Consider testing for Hepatitis B/C, HIV and syphilis depending on the patient and their risk profile
- Urine:
- Urine FWT
- Urine bhCG
For more information refer to the sexual health guidelines in your State or Territory
Pelvic Inflammatory Disease (PID)
PID comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of:
- Endometritis
- Salpingitis
- Tubo-ovarian abscess and
- Pelvic peritonitis
PID can lead to infertility, chronic pelvic pain and ectopic pregnancy.
Sexually transmitted pathogens are more likely to be found in women with PID among younger, sexually active women.
Clinicians should have a high index of suspicion for PID, which is underdiagnosed.
Treatment for PID should cover chlamydia trachomatis and as well as anaerobic organisms which are often associated with PID.
Exclude pregnancy as ectopic pregnancy can present in a similar way.
Mild to moderate severity PID can be managed in an outpatient setting. Women with severe PID should be referred to hospital for intravenous treatment. 1
View resourceRepeat testing
A repeat test for chlamydia to exclude re-infection is recommended at three months, as re-infection rates are high.
'Test-of-cure' is not recommended, apart from in pregnancy.
However, repeat testing should be performed at least three weeks after completion of treatment if symptoms persist or if there is concern regarding adherence or reinfection from an inadequately treated partner.
If a repeat test following treatment is performed it should not be done within 4 weeks of commencing treatment as a persistently positive result could reflect detection of non-viable DNA especially within the first two weeks. 1
View resourcePartner notification
Chlamydia is a notifiable disease and contact tracing is required.
That means Jacinta should advise any sexual partners in the previous six months that they too should be tested and treated. If she has a current partner, they need to avoid unprotected intercourse until seven days after her partner has been treated.
There are many ways that partners can be notified, including:
- The patient simply contacting the person
- The use of online resources such as letthemknow.org.au, https://www.thedramadownunder.info/ for men who have sex with men and www.bettertoknow.org.au for ATSI youths
- Employed contact tracers (in some states)
Other notifiable STIs are:
- Gonorrhoea
- Hepatitis A, B and C
- HIV
- Syphilis
View resourceView websiteScreening for STIs
STIs are on the rise across all age groups in the community, and yet screening in general practice is often overlooked.
Yearly screening for chlamydia is recommended for sexually active people aged 15 to 29.
Those younger than 15 can still be screened; however attention and care should be taken to identify the possibility of abuse.
View guidelinesScreening different populations
Different samples are needed to screen different populations:
- Women:
- Self-collected vaginal swab for chlamydia, gonorrhoea and/or trichomoniasis. First pass urine can be performed when self-collected vaginal swab cannot be taken.
- Serological testing (HIV, Hep B/C, syphilis) only if high risk or requested by patient. This should not be in your routine screening
- Lesbian women still need STI screening
- Heterosexual men:
- First pass urine for chlamydia
- Serological testing (HIV, Hep B/C, syphilis) only if high risk or requested by patient. This should not be in your routine screening
- Men who have sex with men (MSM):
- First pass urine for chlamydia
- Throat swab for gonorrhoea
- Anal swab for chlamydia and gonorrhoea (if having receptive anal sex)
- Blood test for syphilis, HIV and Hep A/B if not vaccinated
- MSM who have multiple sexual partners should be offered three-monthly screening
Download guidelinesGonorrhoea treatment
In almost all areas of Australia, gonorrhoea has become resistant to oral amoxicillin or probenecid and treatment with intramuscular (IM) ceftriaxone is now required.*
There is currently worldwide concern about multi-drug resistant Neisseria gonorrhea and hence, it is recommended to not only treat gonorrhoea with IM ceftriaxone but to always give a stat dose of azithromycin.
This is to cover the high rate of concurrent chlamydia infection, as well as there being some suggestion that it improves treatment efficacy for gonorrhoea alone.
*Gonorrhoea in the NT (outside of Darwin, the Kimberley and cross-border areas of Central Australia) is still considered penicillin sensitive.1
Discussing the possibility of an acute HIV infection
The possibility of an acute HIV infection needs to be discussed with George.
George is at higher risk because he has sex with other males (MSM) and he has recently tested positive to another STI (gonorrhoea).
George’s general psychological state and social supports need to be assessed during the counselling process.
Discussion with George should cover:
- Reason for testing
- Testing procedure
- Window period
- Transmission
- Prevention
- Confidentiality issues and privacy issues around testing
- Implications of positive and negative test results
Discussion should be appropriate to the person’s gender, culture, language, behaviour and risk factors.
You must gain informed consent prior to testing.
For HIV training resources refer to:
view website Window period for HIV tests
It can take 6 to 12 weeks for the body to develop an antibody response following exposure to the HIV virus.
If the initial HIV screening test is negative, a repeat blood test should be done at 3 months.
view website Appropriate counselling regarding a HIV diagnosis
- Give positive test results in person
- Listen and respond to patient needs
- Avoid information overload
- Check immediate plans, supports and available services (e.g. www.napwha.org.au)
- Arrange other tests if appropriate and arrange a specialist appointment
- Make a follow up appointment to review how the patient is coping
- Advise safe practices and condom use
- Arrange contact tracing
view website Next steps in George's management
- Ongoing appropriate counselling regarding the diagnosis and ensure appropriate supports
- Liaise with nearest Public Health Unit or Sexual Health Physician regarding initiation of antiretroviral treatment (will need to be transferred out to a tertiary hosptial)
- Discussion regarding contact tracing (start with the most recent sexual partners)
- Post-exposure prophylaxis can be offered within 72 hours of potential HIV exposure and must be taken daily for 28 days
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