Pharmacists’ significant role in helping patients with STIs needs to be handled with care, write Jarrod McMaugh and Sam Flood
Sexually transmitted infections are a common enough occurrence in Australia that pharmacists should expect to receive enquiries about the symptoms they cause, how to avoid them, how to treat them, and differential diagnosis. A skilful pharmacist will be able to elicit enough details to be able to determine the likelihood of an STI and refer for treatment.
Pharmacists need to be aware that many STIs go undiagnosed or untreated – sometimes for significant amounts of time – before a health professional asks the right questions that eventually lead to a referral or diagnosis. Pharmacists will often be the health professional that a person speaks to most often, so we need to remain aware of the signs, symptoms, and population groups most likely to encounter an STI.
This article will focus on acute STIs, but similar principles apply to chronic sexually transmitted infections such as HIV, hepatitis B, and hepatitis C. This is especially important given the progress in recent years for new treatment options, and in light of the sharp drop-off in the utilisation of direct acting antivirals for hepatitis C despite only a portion of the known population having accessed treatment.
Common STIs in Australia
When considering exposure to STIs, the most common causative organisms in Australia are Chlamydia, Genital Herpes, Gonorrhoea, HPV (warts), syphilis, hepatitis B and C, and HIV. There are a range of other STIs or infections that are associated with sexual transmission that are less common; unusual symptoms should always be referred for follow up and diagnosis.
Always keep in mind that STIs may be asymptomatic, or cause symptoms that are nothing more than “mildly annoying” – this can explain the ability of these infections to transmit effectively within a population in a small period of time. Despite this, the impact of most STIs can be quite serious; identification and treatment shouldn’t be overlooked.
Pharmacists should consider the risk of STIs in people who present for treatment of common urogenital complaints such as thrush or urinary tract infections. Other conditions that are associated with sexual activity, such as transmission of pubic lice or scabies may also be associated with an increased risk of STI transmission. Including questions about recent sexual activity may be appropriate in these situations, leading to a discussion of the individual’s likely exposure and consideration of a referral for further investigation.
Chlamydia is a bacterial infection, and has the highest prevalence of STIs in Australia, with as many as 80% of cases occurring in people aged between 15 and 24. There has been a lot of discussion about the role of social media and dating apps in the increase in Chlamydia within Australia.
Chlamydia is often asymptomatic, but when symptoms occur, they may include discharge, burning or discomfort when urinating, and swelling of the testicles in men. Chlamydia can be responsible for pelvic inflammatory disease, which in turn may cause scarring that may affect the ability of women to become pregnant.
Gonorrhoea is also a bacterial infection, and in Australia is roughly 30 times less common than Chlamydia. People aged 15 to 35 are the most commonly affected age group, with men more likely than women.
Gonorrhoea is also asymptomatic in most cases; when symptoms occur they are often similar to that of Chlamydia, with discharge, uncomfortable urination, testicular pain, and pelvic inflammatory disease.
Syphilis is a bacterial infection that is far less common than chlamydia or gonorrhoea. Syphilis is a spirochete, and this shape allows for proliferation throughout an individual’s organs over time. The most common presenting symptom will be a lesion on the genitals (the primary infection point).
As the infection progresses, the individual may experience rashes on hands and feet, genitals, or a diffuse inflammation over the entire body consisting of papules, nodules, or gummas (very large, soft nodules). Long-term infection may cause issues with the heart, and has been known to cause dementia due to involvement of the brain.
Genital herpes is caused by a virus from the same family as herpes simplex (cold sores) and herpes zoster (chicken pox & shingles). Presenting symptoms are usually a painful/burning blistering rash at the initial site of transmission.
Like other herpes-family viruses, eradication of the virus is unlikely, and the individual will probably experience recurrent symptoms throughout their life.
It should be noted that people may request schedule-3 antivirals to treat this condition. This is not appropriate due to the duration of treatment required, and the need for differential diagnosis; even in patients who are experiencing recurrent symptoms.
Genital warts are caused by a virus of the papilloma family. Similar to herpes, eradication is unlikely, although vaccination against some strains may reduce the recurrence of symptoms. Some strains of HPV are associated with cancerous changes (cervical, anal and throat cancers).
Individuals may describe genital warts specifically, as the lesions themselves are distinctive in nature.
Tact, privacy, and specific population groups
For STIs, diagnosis and treatment will be provided by a health professional such as a General Practitioner, Nurse Practitioner, or Sexual Health Specialist. Despite this, pharmacists may identify people who have an STI without realising. We often see people before they engage with prescribers, especially in cases where symptoms may not be recognised by the individual.
How pharmacists handle this is critical – it is important for pharmacists to consider different risks and rate of presentation for these disparate population groups when discussing the risk of STI, and remaining sensitive to the stigma associated with STIs. Broaching the subject of a potential STI should always be handled in a way that avoids causing offence or embarrassment.
Certain populations of Australians are at a higher risk of STIs than the general population. Aboriginal and Torres Straight Islander populations – especially men who live in remote areas of Australia – are notably over-represented in people who present with STIs, and under-represented in treatment groups.
Men who have sex with men and gay men are also over-represented in populations who present with STIs. Younger populations who are becoming sexually active will also have a higher risk of exposure; as will older people whose sexual partners have expanded due to lifestyle change such as divorce.
For some STIs, a person may present with symptoms many years after the initial infection. This may cause significant confusion and distress, especially for people who have been in a monogamous relationship, who may fear that their partner has not remained monogamous. Pharmacists need to be mindful that we could inadvertently cause distress in these situations.
In situations where a pharmacist is discussing signs or symptoms that may be suggestive of an acute STI infection, relative risk for these populations should always be considered, without stigmatising or pigeon-holing any individual. The discussion should include questions that allow the pharmacist to assess the relative likelihood that presenting symptoms are suggestive of an STI.
Consideration should also be given to patients who are requesting a medication, product, or service that is associated with sexual activity; requests for emergency contraception and candida infection may warrant a discussion about STI risk. It may also be a consideration for people requesting a pregnancy test, treatment for haemorrhoids, or barrier contraception such as condoms.
Symptoms that should trigger a referral
Apart from the issues discussed above, there are some diffuse symptoms that may warrant a referral for further investigation. These symptoms may be associated with an STI, or they may be something else altogether, yet further investigation is appropriate. Pelvic and abdominal pain or discomfort, persistent UTI symptoms, swelling and pain affecting the genitals, and changes in menstrual cycle should result in a referral regardless of the risk of STI.
Specific mention should be given to persistent or painful “thrush” – patients may misidentify vaginal discharge, inflammation, ulceration, or pain as thrush. This is important because “thrush” infection should be referred if any of these symptoms are present. These symptoms suggest that it is another condition altogether, or at the least that it is a complicated case that requires further investigation.
Future potential for pharmacy
As should be expected, there is potential for pharmacy to play a greater role in the identification and treatment of common STIs. The 6CPA included funding for a project that examined the feasibility of Chlamydia screening in people presenting for emergency contraception. Uptake of the service within the study was encouraging, although no of the tests conducted were positive.
Home-testing kits are available in Australia, and these are currently being offered by some pharmacies. These kits involve a take-home test for (usually) Chlamydia and gonorrhoea, with a private pathology request. The results are forwarded to the patient’s nominated GP. This can produce some ethical considerations, since a GP should not be in the position of receiving a pathology result for a patient that they have not consulted with recently (or ever).
It is also important for patients to receive their results from a health practitioner who is then capable of providing treatment if necessary. Pharmacies that are considering such a service may wish to engage with local GPs to ensure continuity of care and communication.
Models for point-of-care testing for STIs in pharmacy exist overseas. Some of these services involve a home-test and pathology request being supplied in a pharmacy, with the results directed to a doctor who then contacts the individual. This is a more structured version of the home-testing kits available in Australia, and follows a similar model to 6CPA research discussed above.
Special mention should be made of Pre-Exposure Prophylaxis (PrEP) – this is the use of antiviral medications to prevent the transmission of HIV. PrEP is available in Australia, but is not currently listed on the PBS, despite excellent evidence of efficacy.
There is an argument to be made that preventing HIV transmission should not be medicalised, and access to this medication should be available without a prescription in those people who have been counselled on the correct method of use and monitoring (ie periodic liver function and HIV antibody screening). There is unlikely to be any advances in access in the near future.
People who have acquired an STI may not experience symptoms, or may not recognise them. Pharmacists, as a health professional with a high level of contact with the community, can help identify people who may have an untreated or undiagnosed STIs.
Pharmacists can identify these individuals by being aware of the individuals most at likely to fall in to this group by asking relevant questions in a tactful and professional manner, then referring as necessary for follow-up screening and treatment.
Jarrod McMaugh is a community pharmacy practitioner with Capital Chemist in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.
Sam Flood is a motivated pharmacy intern at Capital Chemist Coburg North, hailing from remote Tasmania. Sam completed a Bachelor of Pharmacy at UTAS. Although Sam is in the early stages of his career, he has had exposure to a variety of pharmacy settings, including extensive time working in opioid replacement therapy and forensic mental health.