Elements of effective clinical management

The clinic or location where patients are interviewed and examined should, as far as possible:

• be as accessible as possible (consider disability issues)
• be private and secure from interruptions
• provide all the equipment necessary for an examination and for specimen taking (see Nucleic Acid Amplification Tests)
• comply with accepted infection control guidelines¹
• meet the special gender and cultural needs of the local population through careful consideration of entrances and clinic identification.

Rationale: The clinic layout and appointment arrangement should not deter patients from presenting for initial or follow-up assessment. The clinic entrance and reception area should be private, so that patients do not feel that others can identify them as having presented for an STI consultation.

¹Department of Health and Ageing 2004, Infection control guidelines for the prevention of transmission of infectious disease in the health care setting (external site), Department of Health and Ageing, Canberra.

In organising STI/HIV consultations, give priority to the patient's gender and cultural needs.

Respect the cultural needs of communities when scheduling clinics and examining patients.

Rationale: Denial of cultural needs may result in denial of patient access to STI/BBV services. Many people prefer to consult with a provider of the same gender, and this should be arranged whenever possible. Each health service will have different capabilities and resource limitations, which cannot be overcome by dictating standards. However, assistance should be sought from representatives of cultural groups to develop strategies to meet their special needs.

Special considerations

When providing STI/BBV health services to specific cultural groups, the assistance of accredited interpreters may be helpful during history taking, examination, specimen taking, counselling, prevention, education and contact tracing where appropriate.

Taking a sexual, psychosocial and drug history will indicate whether the patient is at risk of STIs/BBVs.;

See History and examination for more information.

In general, test patients presenting for STI/BBV assessment for:

• gonorrhoea
• chlamydia
• syphilis
• HIV
• hepatitis B
• hepatitis A, if symptomatic or if there is a history of male-to-male and/or oro-anal sex and vaccination is contemplated if negative
• hepatitis C, if there is history of injecting drug use.

Consider testing for other non-notifiable diseases, e.g. genital herpes, trichomoniasis.

Steps towards STI/BBV testing with informed consent

It is important for patients to be able to give informed consent prior to testing. A detailed sexual and drug history should be obtained. This will help to determine the level of information required by the patient. See History and examination.

Community screening is defined as mass STI/BBV screening of populations and is only considered in areas of high prevalence.

Any community screening program must meet the following requirements:

• appropriate community representatives should be consulted and asked to endorse the program. They should be invited to help develop protocols for screening and be involved in implementing the screening program
• resources must be adequate to manage detected cases and their contacts
• an education strategy must form part of the screening program, addressing:
  • confidentiality of results (to state clearly how the privacy of the individual will be protected)
  • prevention, including safe sex behaviours.
• screening protocols must contain accepted confidentiality guidelines to protect the privacy of the individuals and communities to be screened
• all individuals must give full and informed consent before being screened
• health service providers who deliver services to the community to be screened should be informed of the start of the program and the protocols to be used. The community will determine which providers should be informed and how this should occur
• all information obtained via the screening program (particularly test results) is the property of that community. None of it should be used for research purposes, or publicised in any way, without the understanding and permission of the community.

* Originally developed by the Kimberley Public Health Reference Group and modified by consultation workshops held at Broome Aboriginal Medical Service and the Centre for Aboriginal Studies, Curtin University of Technology, 1996.

Every STI/BBV consultation is an opportunity for preventive education.

It is important that this education is not judgemental, but some assessment of patient beliefs, sexual practices and culture is required for service providers to understand potential risks and how they might reduce those risks.

Discuss the following points with patients:

• Abstinence while infected. It is particularly important that patients understand that they must not have sex while being treated, to reduce the risk of transmission of their STI. In the case of HIV infection, patients need to understand the need for lifelong safe sexual practices. They also need to be aware of the legal issues associated with knowingly putting another person at risk of HIV infection.
• The advantages of a long-term, monogamous relationship in the prevention of an STI. Encourage patients to discuss their sexual behaviour with their partners and to communicate their sexual needs. It is important to emphasise the need for honesty in the relationship rather than to assume long-term fidelity.
• Use of condoms and water-soluble lubricant. Check that patients know how to use condoms and where to get them. Discuss the issue of negotiating condom use, especially to encourage women to feel that they can raise the subject with their partners. For some women mentioning that female condoms are available might be appropriate.
• Reducing the number of sexual partners. Obviously, the fewer the partners, the lower the risk. It is also important to explain that a series of monogamous relationships without condoms can be just as risky as numerous casual partners.
• STI check-ups. Encourage patients to have STI check-ups, particularly before undertaking any new sexual relationship.
• Other risk behaviours. Review these with the patient and discuss ways to reduce risks. For example, people who inject drugs need sterile injecting equipment and information about needle exchange programs.
• Notification requirements. Explain that some STIs must be reported to health authorities, pointing out the advantages to public health and emphasising that patient confidentiality will be respected.
• Other relevant issues, e.g. contraception, fertility, mental health, alcohol and other drugs, social and occupational situation. 

Child sexual abuse is 'any act which exposes a child to, or involves a child in, sexual processes beyond his or her understanding or contrary to accepted community standards. The child is unable to provide informed consent to and is not developmentally prepared for sexual activity.'

For information on child abuse and neglect visit the Department for Child Protection website (external site). The importance of the definition lies in the acknowledgment of the limitations of children to give truly informed consent and their risk of exploitation.

Child sexual abuse is not acceptable in any group of people. It is not 'just a family matter', but many children are afraid to report an incident to the police because the abuser is often a family friend or relative. Other people who may have concerns about sexual abuse may hesitate to report it because they are not totally certain abuse is occurring. Tragic outcomes of child abuse may occur when reporting is delayed.

Most cases of child sexual abuse do not result in an STI. However, if an STI (such as gonorrhoea, chlamydia, trichomoniasis, genital herpes or genital warts) is diagnosed from the genitalia, throat or other suspicious site of a child or an adolescent under the age of 18 years, then sexual abuse should be considered and a mandatory report of child sexual abuse should be submitted if a view is formed that sexual abuse may have occurred. In addition to the mandatory report, a report on an STI in a child under 14 years of age must also be made by the diagnosing clinician.

• OD 0296/10 Interagency Management of Children Under 14 Who are Diagnosed With a Sexually Transmitted Infection (STI) (external site)

STIs occurring in babies, especially those under 12 months of age could be the result of vertical transmission, so the mother should be tested (and, if she tests positive, her sexual contacts should also be tested). Genital warts in children can also occur as a result of autoinoculation.

• Treat the child for their infection and investigate for other STIs.
• Always ensure a subsequent test of cure.
• Remember there will be at least one other person, probably an adult, who is also infected and who requires contact tracing.
• As a health care provider, you have a responsibility to assist in protecting children who may be victims of child sexual abuse. The occurrence of an STI in a child is strong, circumstantial evidence that abuse is occurring.
• If you require advice about forensic examination please contact the Child Protection Unit at Princess Margaret Hospital on 9340 8646.

Mandatory reporting of child sexual abuse has been introduced by amendments to the Children and Community Services Act 2004(the Act) (external site). From Thursday 1 January 2009, doctors, midwives, nurses, teachers and police officers ('reporters') are legally required to make a report in accordance with the Act when they have formed a reasonable belief that child sexual abuse has occurred or is occurring. The Act places the responsibility for making a report on the reporter. There is a clear duty for all health professionals to appropriately manage child abuse or neglect.

When to make a report

Reporters must make a report if they have formed a belief on reasonable grounds and in the course of their work, that a child:

• has been the subject of sexual abuse that occurred on or after Thursday 1 January 2009
• is the subject of ongoing sexual abuse.

Reports must be made to the Department for Child Protection, which is required under the Act to provide the Western Australia Police with a copy of the report.

Evidence of abuse is not required to make a report. Reporters should not conduct an investigation to establish if there is evidence, as this may jeopardise subsequent investigations by the Department for Child Protection or the Western Australia Police.

Reporters who fail to report a belief that a child is being sexually abused commit an offence and can be fined up to $6000 [s124B(1)].

It is very important to note that mandatory reporting of sexual abuse does not substitute for an STI report in a child under 14 years of age, or in a child aged 14 and up to 16 years of age if sexual abuse is reported and vice versa. If sexual abuse is suspected both reports must be submitted. If there is no abuse only the STI report in a child under 14 years of age is required.

For further information and contact

Please refer to the following documents:

• OD 0296/10 Interagency management of children under 14 who are diagnosed with a sexually transmitted infection (STI)
• Guidelines for protecting children 2015 for information on child abuse and neglect.

Please contact the Department of Child Protection on 1800 708 704 regarding making a mandatory report.

Intimate partner violence (IPV) should be considered in the management of a person who has contracted an STI. Female victims of IPV have a higher STI prevalence (i.e. 1.5 times more likely to acquire HIV and 1.5 times more likely to contract STIs), as well as a higher prevalence of STI-risk behaviours, compared with women in nonviolent relationships.

What is Intimate Partner Violence?

IPV can be defined as any violent or intimidating behaviours perpetrated by current or former intimate partner, boyfriend, girlfriend or date, where they aim to exert power and control over the other, through fear.

Whilst both men and women can perpetrate IPV, most victims are women and children, and majority of perpetrators are men. Within Australia, 25% of women and 8% of men are or have been victims of violence from a current or former partner. Other groups of people more likely to be victims of IPV are young women, pregnant women, women living in regional and remote areas, Aboriginal women, women from new migrant or refugee backgrounds, women experiencing mental health and/or AOD issues, women with a disability; and people in same-sex relationships.

Indicators of Intimate Partner Violence

It can be difficult for a person to recognise they are experiencing IPV. This may be due to ongoing coercive control, manipulation or gaslighting as well as minimisation from the person using violence. Examples of IPV include:

• Isolating the victim from her social networks and supports. This can be done by preventing her from having contact with her family or friends, dictating who she can talk to or where she goes, or by verbally or physically abusing her in front of others;
• Excessively monitoring their movements, internet use and social communications;
• Forcing a person to engage in sexual acts they don't want to do;
• Controlling a person's birth control options;
• Threats to hurt the victim, their children, loved ones or pets;
• Threats to harm themselves;
• Physical assaults (e.g., hitting, beating, punching, pushing, kicking);
• Threats to report the victim to authorities such as Centrelink, Immigration or Child Protection; and
• Financial abuse such as denying a person access to money, incurring debts in the victim's name; selling the victim's possessions; and forbidding a person from working.

Enquiring about a client's safety

If undertaking this interview via phone, first enquire if it is safe for the person to speak with you e.g.'Is anyone listening to your phone call?'. If yes, advise the client to answer yes/no responses to the following questions.

If you suspect a person may be experiencing IPV, you can gently enquire about their relationship and safety. For example:

We know that some women who contract an STI (or name the infection) are at a greater risk of experiencing Intimate Partner Violence. That's why as part of our role we ask all women about their safety.

Suggested Screening questions:

• Do you ever feel afraid of somebody in your home, an ex-partner or family member?
• Has anyone in your family, in a current or previous relationship, ever hurt or threatened to hurt you?
• Has anyone in your family, in a current or previous relationship ever tried to control what you can or cannot do?
• Are you worried about your safety?

*Refer to the WA Health Screening for Family and Domestic Violence form (FDV950) for further guidance.

How you can support a person who discloses Intimate Partner Violence

It takes a lot of courage to disclose IPV. It is important to respond sensitively and in ways that support the needs of the person impacted, including:

• Validate their experience of abuse e.g. 'that must have been frightening for you'; 'it must have been difficult for you to talk about this'.
• Affirm that violence is unacceptable behaviour - 'violence in unacceptable; you don't deserve to be treated this way'.
• Consider completing the Assessment for Family and Domestic Violence (FDV951) with client to ascertain their level of risk and to guide appropriate referrals.
• Support them to connect with additional services.

Referral Pathways

When discussing referral options, you should:

• Ensure immediate safety - if client is in immediate danger consider phoning Police, Women's DV Helpline, Crisis Care or a local support service;
• Refer to a Social Worker (if available);
• Alternatively contact the Women's DV Helpline, Men's DV Helpline; or a specialist FDV service in your area;
• If a patient declines a referral provide information on how to access support and discuss safety planning prior to discharge;
• If the client is in immediate danger and not willing to receive assistance, refer to your delegated authority to consider release of information to a relevant external agency without consent (under section 28B, Children and Community Services Act).

Safety Planning

Use the following prompts to guide your conversation around safety planning with your client. For more comprehensive safety planning contact the Women's DV Helpline, DVassist (in regional WA) or a local FDV support service (see the Resources section below)

• Identify other services that might already be involved.
• Ask about what they are currently doing to keep themselves (and their children) safe.
• Check they know the emergency contact numbers and how they can help you (i.e. Police; Women's DV Helpline; Crisis Care).
• Do they have a way to contact them? (e.g. mobile phone with credit/service, friend, neighbour).
• Do they have a safe place to go and a plan of how to get there?
• Can they identify of a friend/neighbour who can assist in an emergency?

Considerations when discussing Contact Tracing

• Be mindful that the notification to contacts of possible STI may place a client at (further) risk of abuse or of violence escalating.
• Be clear with the client about what may be asked regarding contact tracing and why.
• Discuss if they believe informing the perpetrator will impact their safety.
• Discuss options for contact tracing i.e. PHU to inform perpetrator, timing of notification.
• If the patient appears reluctant, or refuses to cooperate with contact tracing, be considerate of why the client is choosing not to inform their (ex)partner and that they are making a judgement around their safety.
• Discuss scenarios and safety planning. Discuss how the client would like this to be done. The victim/survivor has the best knowledge of how safe/unsafe they are. Listen to the client and take the lead from them where possible on safety planning (see Safety Planning section for further guidance).

Intimate Partner Violence Resources and Support Tools:

• For Department of Health employees, refer to your relevant Health Service Provider's Policies and procedures.
• For WA Country Health Service employees, refer to the WACHS FDV Toolbox for Policy and resources.
• For General Practice settings, refer to the Family and Domestic Violence Health Pathway.

Helplines (24/7)

As a Health Practitioner you can use these helplines to seek advice/support as well as referring clients for confidential counselling and support (24/7):

• Women's DV Helpline: 1800 007 339
• Men's DV Helpline: 1800 000 599
• Crisis Care: 1800 199 008
• 1800 RESPECT: 1800 737 732

FDV Online Support Services Directory:

Directory - Centre For Women's Safety and Wellbeing (cwsw.org.au) (external site).

Counselling is important in managing STIs/BBVs and should be considered at every contact with the patient.

As a minimum, consider counselling at the first presentation and subsequently during treatment and follow-up.

Rationale: Counselling is an opportunity to educate and support the patient in prevention strategies. The key points are:

• building mutual trust and respect
• communicating the confidentiality of the diagnosis, and the reasons for testing and contact tracing
• formulating expectations from treatment
• promoting awareness of risk behaviours.

Counselling should also include discussion of the implications of STI/HIV testing (e.g. testing does not prevent transmission). Emotional reactions can accompany a positive STI/HIV diagnosis, with delayed reactions sometimes occurring several days after the consultation.

General considerations

A pre-test discussion requires patient consent and should address:

• confidentiality
• the reason for the tests
• risk activities
• understanding of statutory notifications
• awareness of the disease process
• awareness of modes of transmission and prevention
• awareness of window periods for the tests undertaken.

Counselling when delivering a negative diagnosis provides an opportunity to reinforce pre-test discussions and prevention education.

Counselling when delivering a positive diagnosis should address:

• patient lifestyle and support systems, including those in whom the patient might confide
• potential for a crisis (e.g. suicide).

If the diagnosis is positive, avoid overloading the patient with excessive information and arrange for further counselling at a later time. During the first and subsequent consultations:

• stress the confidentiality of results and treatment
• confirm the patient's understanding of the infection
• if the patient is ready to deal with more information, provide further details of the infection and how to prevent transmission
• continue to educate concerning risk behaviour
• stress importance of contact tracing
• undertake partner management with careful consideration of the risk of violence (for the client and/or partners) or seek assistance from public health practitioners. For information on how to support a client who may be at risk of intimate partner violence, see section IPV and STI's in General Principles.
• provide information about patient support organisations see contacts for specialist advice on STIs and HIV.

Patients with gonorrhoea or chlamydia should be re-tested (including from oral and rectal sites where this is indicated) for these infections at the three month follow-up. 

Rationale: Patients who have had gonorrhoea and/or chlamydia are at risk of reinfection. 

Patients who have had negative test hepatitis B or C, HIV or syphilis results after presenting for STI/BBV assessment should return three months later to be tested again for:

• hepatitis B and if there is history of injecting drug use, hepatitis C
• HIV
• syphilis.

Rationale: These infections have a 'window period' when the test may not be positive even though the patient is infected. Repeat testing provides an opportunity for further patient education, particularly for high-risk patient groups.

Remember to ask patients about any new symptoms or new risks when they present for follow-up testing.