Previous service

At the time of this intervention, our central integrated sexual health service was using a text appointment system, whereby individuals could text a number the night before they wanted an appointment and an appointment for the following day would be sent to them. A number of walk-in appointments were also available each day. Individuals who attended without symptoms were invited to complete paper-based asymptomatic self-screening questionnaires and could see a HCSW for testing for chlamydia, gonorrhoea, HIV and syphilis; those with symptoms saw a trained staff member for a full history. Community clinics ran a walk-in system with asymptomatic chlamydia and gonorrhoea testing only. However, those attending the central service that identified as MSM on the self-screening questionnaire were referred to a trained staff member for a full history to be taken; many were also then referred to a health advisor if identified as having been at high risk. If MSM attended community clinics, they were referred to the central service. No other groups were excluded from the pathway if they were asymptomatic; those with other high-risk factors (eg, injecting drug users) could complete the tests with a HCSW and were then were advised to see a health advisor.

Following feedback from both staff and service users, it became apparent that some MSM felt the current service discriminated against them; this was concerning as the perception that a service is judgemental or discriminatory may be a barrier to future testing.13 Also, long waiting times were deterring MSM from using our service again. Furthermore, we were keen to develop a pathway that might improve overall capacity to allow more MSM, and clients in general, to be seen within the constraint of limited resources. In view of this, we decided to develop and pilot an asymptomatic pathway for MSM.

Developing a new pathway

We initially contacted other UK clinics to ascertain if other services were using MSM asymptomatic screening pathways; one clinic responded and shared their pathway. Many other services said that they too currently did not include MSM in their asymptomatic pathway. The doctors within our service then discussed this and decided to adapt our current asymptomatic pathway with elements from the other services' pathway. It was felt to be important to include questions that allowed high-risk MSM to be identified and directed to a health advisor following their testing.

The asymptomatic pathway previously in use contained information about the pathway, questions to ensure the person was asymptomatic and not a known contact of an STI and questions regarding domestic violence and higher risk factors for HIV (including injecting drug use, from a high-risk country, commercial sex work, HIV positive or previous partner with these factors). This was updated to include questions for MSM (table 1). HCSWs would then offer three-site testing for chlamydia and gonorrhoea and screening for HIV, syphilis and hepatitis B, and hepatitis C when indicated. As all MSM should be offered hepatitis B vaccination if not already immune,7 those who answered ‘no’ or ‘unsure’ to having been vaccinated were directed to a trained staff member following their tests for offer of vaccination. Those who answered ‘yes’ to this being their first time in clinic, having had condomless anal sex within the last 3 months or having used drugs before or during sex were directed to a health advisor following testing for health promotion discussion and offer of onward referral to other services (such as drug and alcohol services) for those that may require it. Universal testing of hepatitis C among MSM is not recommended;7 we advised that those who have had condomless anal sex within the last 3 months or having used drugs before or during sex are tested. Routine hepatitis A vaccination is not recommended in the UK, except in times of local outbreaks, and therefore was not included in the pathway.

Implementing the pathway

All staff provided feedback on the initial document; the pathway was then updated and piloted over 4 weeks with 20 asymptomatic MSM attending the service who agreed to participate and provide feedback on the pathway. They were all also seen by a trained member of staff or health advisor in addition to a HCSW to ensure that the pathway was clinically safe. Feedback from staff and service users was generally positive. Two MSM who had previously attended our service commented that the pathway was quicker and straightforward to use, and would encourage them to return regularly for repeat testing. Minor adjustments were made to the document's wording to make it clearer for both staff and users. The written information was extended to include information that may traditionally be covered as part of pretest or post-test counselling, such as information about HIV and postexposure prophylaxis.14 The pathway was then rolled out in the central clinic. A 4-week notes review after roll-out showed that the proforma was being used appropriately. There are plans to extend the pathway to community clinics, to improve physical accessibility, and acknowledging that some MSM prefer not to use central specialist services.15 The pathway will continue to be assessed and updated as required. The clinic has also recently changed its booking process to improve accessibility, and specific fast-track clinics for asymptomatic patients have been created.

Discussion and conclusions

Increasing screening and reducing STIs among MSM will likely require a variety of different concomitant approaches16 varying according to local services, populations and local available funding resources. There is wide variation in sexual health funding across the UK so pathways that have been implemented elsewhere may not always be locally possible or appropriate. Asymptomatic screening pathways may be one approach to decrease STI rates. However, there is a lack of good evidence about how best to promote MSM asymptomatic testing17 and no clear guidance around screening pathways that do not involve seeing a qualified practitioner. This service does not currently offer point-of-care or home testing services. Pathways that include point-of-care testing may further increase convenience and allow more patients to be seen, through eliminating the need to see a member of staff entirely.18 Home testing is acceptable among MSM, particularly due to eliminating clinic waits,12 and it may increase testing frequency.12 ,19 However, it is not recommended for replacing clinic testing, but rather as a supplementary strategy.7 Furthermore, some service users prefer seeing a staff member20 and these pathways have been criticised due to the need for hepatitis B vaccination and safer sex promotion among MSM.21 The ability for referral to, or request to see, a qualified practitioner is therefore an important feature of our service. Allowing for electronic registration and filling in of questionnaires may further increase acceptability and testing frequency and speed up this pathway by allowing more patients to register per clinic,22 reducing waiting times and length of consultation.23

This pathway could be criticised for not asking about a comprehensive recommended range of potential high-risk behaviours or hepatitis C risk factors.7 This was due to trying to achieve a balance of asking enough questions while not overloading the form. However, there is a lack of consistent evidence about what constitutes ‘high risk’.7 One study found defining high risk as unprotected anal intercourse, 10 or more partners in the last 6 months, chemsex or group sex showed the greatest potential gains.24 Our questions aim to identify high-risk sexual behaviours and those who require hepatitis C testing, and those who have not visited our service before, to ensure that all MSM are being seen in person at some point. Moreover, during the pilot, no patients were identified as high risk by the health advisors who had not been picked up by the screening questions.

Efforts to improve services and service accessibility for MSM are constrained by resource limitations. We believe that we have developed a model for asymptomatic screening among MSM that could reduce clinic visit duration, improve accessibility and allow trained staff time to manage more complex patients, without the need for additional resources. This pathway also allows for risk identification and health promotion among MSM who may be at higher risk. Further research validating asymptomatic pathways and methods for risk profiling, and evaluating whether pathways such as this encourage both new and repeat attendances would be valuable.