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Introduction
This guideline relates to the following patient groups presenting with no symptoms:
- Cisgender women (cis woman) - someone who identifies as a woman and was assigned female at birth
- Cisgender men (cis man) - someone who identifies as a man and was assigned male at birth
- Gay, bisexual and other men who have sex with men (MSM)
- Transgender people
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- Transgender man (trans man) - a man who was assigned female sex at birth
- Transgender woman (trans woman) - a woman who was assigned male sex at birth
Patients presenting with urogenital symptoms are managed according to their clinical presentation as outlined in relevant section.
Patients presenting as a contact of a person diagnosed with an STI are managed according to the individual infection. If infection is unknown and the patient is asymptomatic, test according to corresponding testing table below.
- Outcomes
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Procedure
Before testing, undertake a STI and BBV risk assessment and take a sexual health history to determine the following
- Medical history including current allergies and medications
- Vaccination history
- Social and sexual history including risk factors for HIV
- Clinical and symptomatic history to determine what tests to perform.
Cis Women
STI tests: Cis women Nucleic acid amplification test (NAAT) for chlamydia and gonorrhoea Self-collected vaginal swab or urinea, Self-collected anal swabb A Cervical Cancer Screening test should be considered in cis women who are overdue (more than 4 years since last Pap or 7 years since last HPV test) or who have never screened and meet the screening criteria. Cis women being investigated for abnormal vaginal bleeding require both human papillomavirus (HPV) and liquid-based cytology as diagnostic testing.
a Urine for NAAT for chlamydia and gonorrhoea can be collected if cis woman declines a self-collected vaginal swab or has had a hysterectomy. Consider clinician collection if the patient requests examination.
b Collect anal swab for chlamydia and gonorrhoea NAAT if woman reports only unprotected receptive anal intercourse or specifically requests an anal swab.
Serology: cis women Infection Testsa Indication HIV HIV antibody/antigen Recommended as part of a full STI screen for all patients. Syphilis T. pallidum antibody (EIA or equivalent) (positive result confirmed by TPPA/TPHA and RPR)
Consider RPR (alone) for monitoring response to treatment and previously treated syphilis.
Recommended as part of a full STI screen for all patients. Note on the laboratory form if the patient has been previously treated for syphilis or suspected early infection.
Hepatitis Bb Hepatitis B surface antigen (HBsAg)
Antibody to hepatitis B virus core (anti-HBc)
Antibody to hepatitis B virus surface (anti-HBs)*Follow local guidance to determine the specific tests to requestConfirm infection and immunisation status if unknown. Offer vaccination c to people in the following groups: sex workers; people from high-endemicity countries; Aboriginal people; people living with HIV or hepatitis C; people with a history of injecting drugs; and people who have been incarcerated.
Consider testing for immunity (anti-HBs) and offering vaccination to nonimmune
Hepatitis C Hepatitis C virus antibody (HCV Ab)
(Hepatitis C virus RNA for those with a past history of Hepatitis C Ab.)As needed based on risk assessment and patient request, and at least annually in the following groups: people living with HIV or chronic hepatitis B; people with a history of injecting drugs; Aboriginal people; people who have been incarcerated.
a Tests are intended as screening tests to determine disease or immune status. Additional tests may be required based on clinical presentation and membership of a priority population. Consider window period prior to ordering test.
b In high-risk people previously vaccinated as adults consider testing for anti-HBc if prevaccination testing was not performed.
c anti-HBs testing 4-8 weeks after vaccination is recommended for contacts of chronic HBV, MSM, SIW, people living with HCV or HIV
Cis Men
STI tests: cis men Test Urine specimen Nucleic acid amplification text (NAAT) for chlamydia Yes NAAT for gonorrhoea Add based on epidemiological risk or if client presents as a contact of an STI case where the diagnosis of the index case is unknown Serology: cis men Infection Testsa Indication HIV HIV antibody/antigen Recommended as part of a full STI screen for all patients. Syphilis T. pallidum antibody (EIA or equivalent) (positive result confirmed by TPPA/TPHA and RPR)
Consider RPR (alone) for monitoring response to treatment and previously treated syphilis.
Recommended as part of a full STI screen for all patients. Note on laboratory form if patient has been previously treated for syphilis or suspected early infection.
Hepatitis Bb Hepatitis B surface antigen (HBsAg) Antibody to hepatitis B virus core (anti-HBc)
Antibody to hepatitis B virus surface (anti-HBs)*Follow local guidance to determine the specific tests to request
Confirm immune status and immunisation statis if unknown. Offer vaccination c in following groups: sex workers; people from high-endemicity countries; Aboriginal people; people living with HIV or hepatitis C, people with a history of injecting drugs; people who have been incarcerated.
Consider testing for immunity (anti-HBs) and offering vaccination to nonimmune marginalised young people who may not have had school vaccinations.
Hepatitis C Hepatitis C virus antibody (HPV Ab)
(Hepatitis C virus RNA for those with a past history of Hepatitis C Ab)As needed based on risk assessment, patient request, and at least annually in the following groups: people living with HIV or chronic hepatitis B; Aboriginal people; people with history of injecting drugs; people who have been incarcerated.
a Tests are intended as screening tests to determine disease or immune status. Additional tests may be required based on clinical presentation and membership of a priority population. Consider window period prior to ordering test.
b In high-risk people previously vaccinated as adults, consider testing for anti-HBc if prevaccination testing was not performed.
c anti-HBs testing 4-8 weeks after vaccination is recommended for contacts of chronic HBV, MSM, SIW, people living with HCV or HIV
Men who have sex with men (MSM)
3-monthly testing is recommended for all men who have had any type of sex with another man in the past 3-months. Annual testing at minimum should be considered for those who are not sexually active or in monogamous relationships. All MSM, including those who also have sex with women, should be offered anal swabs even if they do not report receptive anal sex.
STI tests: MSM Tests Pharyngeal swab Urine specimen Self-collected rectal swab Nucleic acid amplification test (NAAT) for chlamydia Yes Yes Yes NAAT for gonorrhoea Yes Yes Yes Serology: MSM Infection Testsa Indication HIV HIV antibody/antigen 3-monthly if client is HIV-negative. Syphilis T. pallidum antibody (EIA or equivalent) (positive result confirmed by TPPA/TPHA and RPR)
Consider RPR (alone) for monitoring response to treatment and previously treated syphilis.
3-monthly. Note on laboratory form if client has had previously treated syphilis or suspected early infection Hepatitis A Hepatitis A total antibody Recommended to confirm immune status. If client is not immune, vaccinate . Services to provide at least first dose free. Hepatitis Bb Hepatitis B surface antigen (HBsAg) Antibody to hepatitis B virus core (anti-HBc)
Antibody to hepatitis B virus surface (anti-HBs)
*Follow local guidance to determine the specific tests to request
Confirm infection and immunisation status if unknown. Offer vaccination d to all MSM. Consider testing for immunity (anti-HBs) and offer vaccination to nonimmune marginalised young men who may not have had school vaccinations. Hepatitis C Hepatitis C virus antibody
(Hepatitis C virus RNA for those with a past history of Hepatitis C Ab)Annually if : - living with HIV
- have a history of injecting drug use.
a Tests are intended as screening tests to determine disease or immune status. Additional tests may be required based on clinical presentation. Consider window period prior to ordering test.
b In high-risk people previously vaccinated as an adult consider testing for anti-HBc if prevaccination testing was not performed.
c In men who do not report past vaccination, commence vaccination at first visit; do not wait for serology results.
d anti-HBs testing 4-8 weeks after vaccination is recommended for contacts of chronic HBV, MSM, SIW, people living with HCV or HIV
For full details and rationale refer to the STIPU STI/HIV testing guidelines for MSM.
Transgender people
The test, site and frequency of testing for STIs and BBVs will depend on the anatomy of the transgender person and type of sexual activity practised. For further details on taking a sexual health history in a transgender person refer to Sexual health history.
STI tests: trans womena,b Test Pharyngeal swab Urine specimen Self-collected anal swab Nucleic acid amplification test (NAAT) for chlamydia If history of oral sex (fellatio) with men Yes If client reports receptive anal intercourse or specifically requests an anal swab NAAT for gonorrhoea If history of oral sex with men Based on epidemiological risk, or if presents as contact of STI case whose diagnosis is unknown If client reports receptive anal intercourse or specifically requests an anal swab Serology for BBVs See Serology table below a Transgender women are people assigned to male sex at birth but with a female gender identity.
b For transgender women who have had gender reassignment surgery including genital reassignment (creation of a neovagina), the role of vaginal specimens for chlamydia and gonorrhoea is unknown. Urine testing recommended.
STI tests: trans mena Tests Urineb Pharyngeal swab Self-collected vaginal swab Self-collected anal swab NAAT for chlamydia Yes Yes Offer and collect if patient prefers to urine Collect if reports receptive anal intercourse or specifically requests an anal swab NAAT for gonorrhoea Yes Yes Offer and collect if patient prefers to urine Collect if reports receptive anal intercourse or specifically requests an anal swab A Cervical Cancer Screening test should be considered in any person with a cervix who are overdue (more than 4 years since last Pap or 7 years since last HPV test) or who have never screened and meet the screening criteria. Anyone with a cervix being investigated for abnormal vaginal bleeding requires both human papillomavirus (HPV) and liquid-based cytology as diagnostic testing.
a Transgender men are people assigned to female sex at birth but with a male gender identity. Discuss cervical screening with clients who have a cervix.
b For transgender men who have undergone gender reassignment surgery including completed genital reassignment, urine specimens are recommended.
c anti-HBs testing 4-8 weeks after vaccination is recommended for contacts of chronic HBV, MSM, SIW, people living with HCV or HIV
Serology: transgender people Infection Testsa Indication HIV HIV antibody/antigen Recommended as part of a full STI screen for all patients. Syphilis T. pallidum antibody (EIA or equivalent) (positive result confirmed by TPPA/TPHA and RPR)
Consider RPR (alone) for monitoring response to treatment and previously treated syphilis.
Recommended as part of a full STI screen for all patients. Note on laboratory form if patient has had previously treated syphilis or suspected early infection. Hepatitis Bb Hepatitis B surface antigen (HBsAg) Antibody to hepatitis B virus core (anti-HBc)
Antibody to hepatitis B virus surface (anti-HBs)
*Follow local guidance to determine the specific tests to request
Confirm infection and immune status if unknown. Offer vaccination c to all transgender patients of PFSHC. Consider testing for immunity (anti-HBs) and offering vaccination to nonimmune marginalised young people who may not have had school vaccinations. Hepatitis C Hepatitis C virus antibody (HCV Ab)
(Hepatitis C virus RNA for those with a past history of Hepatitis C Ab)As needed based on risk assessment and patient request. Test at least annually in the following groups: Trans people living with HIV, PrEP, trans people with chronic hepatitis B; trans people with an ongoing history of injecting drugs; Aboriginal trans people; and trans people who have been incarcerated.
a Tests are intended as screening tests to determine disease or immune status. Additional tests may be required based on clinical presentation and membership of a priority population. Consider window period prior to ordering test.
b In high-risk people previously vaccinated as adults, consider testing for anti-HBc if prevaccination testing was not performed.
c anti-HBs testing 4-8 weeks after vaccination is recommended for contacts of chronic HBV, MSM, SIW, people living with HCV or HIV
Sex workers (cis men, cis women, bi-sexual, MSM, trans men and trans women)
Frequency of testing will vary according to state legislative and regulatory requirements, as appropriate for the frequency and nature of work, and following any risk episodes such as condom breakage.For cis men, MSM and trans women sex workers follow guidelines according to sexual practices in private life and work. For cis women and trans men sex workers add a pharyngeal NAAT and consider offering an anal.
Education - Ensure all workers are aware of and have contact resources for sex worker organisations. These include Scarlet Alliance and SWOP.
Certificate of attendance
Below is an example of wording which can be used if a certificate of attendance is requested by the worker. In NSW, workers are not legally required to provide copies of results to employers.
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Documentation
Documentation of sexual health history and STI BBV risk assessment.
Document STI and BBV tests including site of specimen collection and whether the sample was self-collected by the client.
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References and further reading
General
- NSW STI Programs Unit. STI/HIV testing tool. Sydney: NSW Health; 2017. Available at: https://stipu.nsw.gov.au/wp-content/uploads/STI-HIV-Testing-Tool-online-version-2.pdf
- Australasian Sexual Health Alliance. Australian STI management guidelines for use in primary care. Sydney: ASHM; 2018. Available at http://www.sti.guidelines.org.au/
Sex workers
- US Centers for Disease Control and Prevention. 2015 sexually transmitted diseases treatment guidelines. Atlanta (GA): CDC; 2017. Available at:, http://www.cdc.gov/std/tg2015/
- Family Planning NSW. Reproductive & sexual health: an Australian clinical practice handbook. 3rd ed. Ashfield (NSW): FPNSW; 2016.
- Ward KF, Menzies RI, Quinn HE, Campbell-Lloyd S. School-based vaccination in NSW. NSW Public Health Bulletin. 2010;21(9–10):237–42. Available at: http://www.phrp.com.au/wp-content/uploads/2014/10/NB10046.pdf
- Sex Workers Outreach Project (SWOP). What we do. Sydney: SWOP; 2017. Available at: https://swop.org.au/what-we-do
Transgender people
- World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th version. WPATH; 2011. Available at http://www.wpath.org/publications/soc
- Wesp L, et al. Transgender patients and the physical examination. San Francisco, CA: Center of Excellence for Transgender Health, University of California, San Francisco. Available at http://transhealth.ucsf.edu/trans?page=guidelines-physical-examination
- Australasian Sexual Health Alliance. Transgender. In: Australian STI management guidelines for use in primary care. Sydney: ASHM; 2018. Available at http://www.sti.guidelines.org.au/populations-and-situations/transgender