To the Editor:
I reflect on the editorial “STD Surveillance”1 and associated Swedish study2 with interest and reservations.
My interest in STD surveillance data for genitourinary medicine (GUM) Clinics in the United Kingdom is clinical. We have used national and local GUM clinic surveillance data and exploited it for the following clinical and service purposes:
1. To provoke a sense of proportionality and significance in the minds of health care purchasers.
2. To stimulate interest and necessity between primary and secondary care clinicians.
3. To organize and redirect local services towards areas of need.
4. To inform the process of STD clinical audit for the purpose of clinical governance.
My reservations stem from the observation that STIs data represent, mostly, cases of diagnosed conditions for local GUM and sexual health clinics.
We must treat national surveillance data with caution where the clinical interpretation would fall beyond reasonable scientific and demographic expectations. Our clinical experience suggests that some primary care and private practice physicians treat many conditions of genitourinary infections empirically, without the prior request of microbiologic investigations. We have encountered, over the years, patients presenting with requests of tests to exclude sexually transmitted infections (STIs) (having been on a recent course of antibiotics prescribed empirically by a general practitioner after a casual sexual encounter). It is difficult to estimate the extent of the practice, as we would only learn of the patients and conditions presenting to us.
It is almost impossible to predict the number of cases that may have received treatment in this manner without attending the local GUM clinic. Patients may also attend another clinic outside the area or choose to use a fictitious name.
We have encountered patients who admitted to multiple and frequent casual partners, over a number of years, and who have received repeated empirical treatments from gynecological and urological units (for clinically diagnosed cervicitis, pelvic inflammatory disease, prostatitis, and/or urethritis). Some have admitted to refusing to take tests for sexually transmitted infections. Others gave a history of requesting the physicians to treat the conditions on a clinical basis. Understandably, the record of STIs on the patient’s own identified general practitioner, hospital, and/or private practice notes is viewed by the patient and the medical practitioner with social and personal significance.
The identification of conditions where patients have sought alternative routes to receive empirical treatment, which mask the diagnosis of a concomitant STI, should be interpreted with caution. This pattern of clients’ behavior could well be replicated in other health care settings, where the final testing and diagnosis of STIs is fraught with bias (especially in health care settings where anonymity and/or confidentiality of the patient’s condition may not be viewed by clients as robust or stringent enough to protect their own personal information and liberty).
There is a pitfall of interpreting STI data as an indication of high incidence between the socially disadvantaged and lower classes, while the element of poor testing, diagnosis, and/or recording for STI could have some impact on distortion of data. The rule of social instability, low socioeconomic standards, poor education, and/or interpersonal breakdowns is understandably going to reflect on acquisition of STIs. The same factors will make the patient seek a health care avenue that is free or governmentally based, which would lead to a cascade of testing, microbiology investigations, and laboratory identifications of STIs.
On the contrary, a patient from a higher social class who is well informed and has better access to private health care could be articulate enough to make a personal case for receiving treatment without prior testing and consequently masking the STI diagnosis, with no record of STIs in clinical records or surveillance data.3
1. Zwahlen M, Spoerri A, Gebhardt M, et al. Surveillance systems for sexually transmitted disease in Switzerland. Sex Transm Dis 2007; 34:76–80.
2. Kent C. STD surveillance: Critical and costly, but do we know if it works? Sex Transm Dis 2007; 34:81–82.
3. Lowndes CM, Fenton KA. Surveillance systems for STIs in the European Union: Facing a changing epidemiology. Sex Transm Infect 2004; 80:264–271.