Abstract
National guidelines give advice on topics which should be covered when counselling patients with a new diagnosis of genital herpes (HSV) with the aim of reducing transmissions. This three-site UK audit of documentation of counselling for patients with a new diagnosis of genital herpes reviewed the records of 284 patients. Documentation in all areas of counselling was limited and this may result in adverse medico-legal consequences for patients and clinicians.
Introduction
British Association for Sexual Health and HIV (BASHH) 1 and International Union Against Sexually Transmitted Infections (IUSTI) 2 guidelines give advice on topics which should be covered when counselling patients with a new diagnosis of genital herpes, including natural history, asymptomatic shedding, managing transmission risk (disclosure, selective abstinence, condoms), specific issues in pregnancy, therapy options (including suppressive therapy), and provision of written resources. In England a prosecution in 2011 (and subsequent appeal in 2014) 3 for the transmission of HSV-2 raised further concerns around quality and documentation of patient counselling. 4 The aim of this multi-site audit was to review documentation of herpes counselling provided at initial diagnosis, against BASHH and IUSTI herpes guidelines standards.
Methods
This audit was conducted in November 2018 at three large, level 3 sexual health services in England. Each service reviewed the first 100 patient records, identified by GUMCAD code C10A (new genital herpes diagnosis) with a laboratory confirmed diagnosis of HSV, from July 2017 to February 2018. All documented counselling provided in the first six months following diagnosis was reviewed. Data were collected on demographics and records of any counselling provided classified into topic areas based on BASHH 1 and IUSTI 2 herpes guidelines. Data were analysed using IBM SPSS v 25, and p values chi-squared.
Results
15% (45/300) of reviewed records contained incorrect C10A codes either due to duplicate coding, recurrent herpes coded as first episode, and negative HSV laboratory results. Data on 284 patients were collected – site C had all data missing on 16 patients who were excluded from analysis.
Demographic and herpes-related data are shown in Table 1. Patients had a mean age of 30 years and a majority were female and white British. There were significant differences between sites in ethnicity (p < .001) and HSV type (p < .001).
Demographic and herpes-related data.
Counselling topics documented in the patient record as discussed are shown in Table 2. There were wide differences between documentation at different sites. Pregnancy issues (37/181, 20% versus 7/103, 7%, p = .002) and future therapy options (60/181, 33% versus 20/103, 19%, p = .01) were recorded as discussed more often with females than males. There were some age-related differences, with reducing transmission risk (54/118, 46% versus 45/166, 27%, p < 0.001), asymptomatic shedding (52/118, 44% versus 54/166, 33%, p = .048) and pregnancy issues (25/118, 21% versus 19/166, 11%, p = .025) more likely to be discussed with those aged ≤25 years.
Counselling topics documented as discussed.
Discussion
Documentation of counselling was limited across all sites, with some minor gender- and age-based differences. All counselling topics, including pregnancy, should be discussed with all patients regardless of gender and age.
It is not possible to determine whether the counselling took place and was not documented, or did not occur. Previous herpes mystery shopping studies at UK sexual health clinics suggest that counselling which patients receive may at times be inaccurate, incomplete or confusing.5–7 Further studies suggest that medical documentation of interventions which have occurred may be limited by a number of factors including lack of prioritisation by staff, time pressures, clinical workload, and lack of resources, and that the targeted development of existing electronic patient records may assist with improving documentation and outcomes.8–10
It should be noted that in the only UK prosecution for the transmission of HSV-2, counselling in line with BASHH guidelines was assumed to have taken place despite lack of documentation. 3 , 4 A subsequent single-site study of sexual health care practitioners in the UK found that the majority had not changed their practice following the case, and continued to advise patients to disclose, although they remained concerned about the wider impacts of legal cases on themselves as professionals and on their patients. 11
Concerns remain about patient knowledge retention following face-to-face counselling. 12 Patient leaflets have been demonstrated to increase patient knowledge and satisfaction, but these may not be utilised by patients either due to limited health literacy or by choice, and so should be considered to enhance rather than replace verbal counselling. 13 , 14 Patient leaflets on genital herpes are freely available although these vary in the balance achieved between detail and brevity, and organisations producing such leaflets, including BASHH, may need to consider how best to manage this balance to maximise patient’s understanding and retention of knowledge. 15 , 16
Limited documentation leaves clinicians vulnerable to medico-legal challenge from patients, such as following transmission of HSV in pregnancy resulting in neonatal herpes. Clinics should therefore consider developing strategies to improve documentation of counselling, such as using electronic counselling check lists which ensure that all counselling topics are covered and accurately documented.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
