Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Emergency contraception seekers need STI testing
- Jan Clarke (19 May 2001)
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Pharmacists and sexually transmitted diseases
- Joseph Watine (20 May 2001)
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Collaboration is vital
- Gary Ward (24 May 2001)
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Pharmacists, EHC and STIs
- Paul Bissell (25 May 2001)
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The price of a toothbrush and other irrelevances
- Philippa James (31 May 2001)
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Re: STI's are very relevant
- Trevor Stammers (8 June 2001)
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Pharmacists seize the opportunity
- Rebekah Cooke (9 July 2001)
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Jan Clarke, consultant GU physician Pinderfields, Wakefield
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I totally concur with your correspondent's concern about pharmacists and sexual health. In a survey of our local community pharmacy services, there was poor knowledge of the location, opening times and even number of GU clinics within our district in the pharmacists responding.(ref) Many expressed reservations about talking about sexual health matters in their pharmacies, and few had formal training in sexually transmitted infection management. Our local family planning services, in an audit 2 years ago, found 25% emergency contraception seekers were chlamydia positive.Chlamydia is not the only concern in young women. We also experienced an increase of 106% in gonorrhoea cases in the Wakefield district in the past year, and are worryingly close to the Manchester syphilis/HIV outbreak. Although few of the young ladies in our catchment area may be able to afford the over-the-counter emergency contraception, those who do buy it should also have access to a sexual health clinic able to screen and treat them for other conditions associated with sexual intercourse. Pharmacists need to develop their knowledge of local sexual health services and be confident in taking sexual histories before they embark on dispensing emergency contraception. (ref)Over the counter advice for genital problems:The role of the community pharmacist. Ralph SG Preston AD Clarke J Accepted for publication March 2001. Int J STD AIDS |
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Joseph Watine, Pharmacien Biologiste Hôpital de Rodez
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Rather than criticise the whole profession of pharmacists, without taking into account the fact that some of them (including me) have not only been taught about sexually transmitted diseases, but also they could teach the question to a number of medical doctors, it would certainly be more constructive to propose that all pharmacists should be taught about sexually transmitted diseases, and be paid for this service to the patients and to the community. |
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Gary Ward, Dispensary Manager Auckland Hospital
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The issue of pharmacists providing emergency contraception is a controversial one, and one that I must admit I am still uncertain about. Whilst the recent re-classification of emergency contraception can only broaden access to this useful product I would have reservations about selling this item myself, not for any issue of conscience (although this is causing great debate in the UK pharmacy literature) but because most UK community pharmacies simply do not have the facilities to take a history in private. If pharmacists are going to provide this service then, as Dr Stammers suggests, they should also be providing information about local sexual health services and advocating their use. Contact your local sexual health centre and discuss this issue with them and you will find that they are only too willing to help with the provision of relevant materials. This issue has the possibility to develop into yet another of those 'them and us' scenarios between the medical and pharmacy professions. Surely the time has come for everyone to work towards a common goal rather than everyone working in isolation. |
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Paul Bissell, Lecturer in Social Pharmacy University of Nottingham
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We write in response to Trevor Stammer’s letter (BMJ 2001 322:1245) regarding his anxieties about community pharmacy supply of emergency hormonal contraception (EHC) and the effect this may have on the spread of sexually transmitted infections (STIs). Stammers states that women in need of EHC will be at risk of STIs. This is clearly an important issue. However, we need to proceed with caution here. Many of the women needing EHC are using the pill and have forgotten to take it, or are in stable relationships. Where a woman wishes to obtain EHC because she has missed taking the oral contraceptive pill (for whatever reason) there is no increased risk of contracting STIs; thus pharmacy supply will have no impact on the spread of STIs. Where a woman is attending for EHC because of a burst condom or due to an episode of unprotected sex, there is more clearly a risk of contracting STIs, but the level of risk is not directly affected by the wider availability of EHC via the pharmacy. Indeed if women are at risk of STIs the last thing they need is an emergency IUD: the quick and accessible supply of Levonelle is even more pertinent here. Stammers is wrong to imply that pharmacists provide sub-optimal care because they do not make reference to STIs when supplying EHC. The Lambeth, Southwark and Lewisham (LSL) Health Action Zone, Patient Group Direction (PGD) for Access to EHC makes specific reference to STIs, as does the PGD for Manchester, Salford and Trafford (MST) Health Action Zone. Furthermore, during our (ongoing) evaluation of the schemes in LSL and MST, STIs were a central concern of the pharmacists involved. Stammers may wish to bear in mind the views of women clients, who suggested that when obtaining EHC (from whatever source) they were most concerned about averting pregnancy, rather than contracting STIs. Whilst we should not be complacent about the spread of STIs, the consultation itself may not be the most appropriate “teachable moment.” Leaflets and other means of providing individualised, tailored information also need to be considered. Stammers is right to point to the possibility of risk “displacement”, i.e. the potential rise in the incidence of STIs as a result of pharmacy supply. However, this may be conflating two quite dissimilar risks: the risk of an unplanned or unwanted pregnancy with the risk of STIs. At present there are few indications that women are changing their contraceptive behaviours because of wider availability of EHC. The evidence from our evaluation is that women (largely) behave responsibly in relation to their use of contraception. Nonetheless, the wider availability of EHC and its impact on women’s (and men’s) sexual and contraceptive behaviour is one that requires further empirical exploration. Paul Bissell, Lecturer in Social Pharmacy, University of Nottingham. Claire Anderson, Director of Pharmacy Practice and Social Pharmacy, University of Nottingham. Lesley Bacon, Consultant in Community reproductive Health, South London NHS Trust. Beth Taylor, Pharmacy Manager, Community Health, South London NHS Trust. Karen O’Brien, Project Co-ordinator Manchester, Salford and Trafford HAZ |
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Philippa James, Senior Clinical Medical Officer Brook in Manchester
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EDITOR – I write in response to the letter dated 19 May 2001 by Trevor Stammers regarding pharmacy supply of emergency contraception. I would agree that unprotected sex carries with it both the risk of pregnancy and sexually transmitted infections. Dr Stammers states that women presenting for emergency contraception should be counselled regarding the risk of sexually transmitted infection. I wonder whether he has the same view about women attending pharmacies for pregnancy testing as they have also, by his criteria, a risk of sexually transmitted infection. Furthermore, I would like to take issue with his comments about the Manchester pilot scheme which provides emergency contraception from pharmacists free of charge. It is clearly stated in the patient group direction to all pharmacists that women should be given a leaflet about sexually transmitted infection and information about local genito-urinary clinics. Women attending the Manchester scheme are also issued with free condoms to limit any further exposure to infection and pregnancy. To make a suggestion that this issue was ignored in Manchester is inaccurate and misleading. I’m sure that Dr Stammers is aware of the futility of testing for a sexually transmitted infection such as chlamydia within 72 hours of exposure and I cannot understand his objection to pharmacies supplying emergency contraception on these grounds. On a more practical note the cost of Levonelle sold in pharmacies is £20 which is much more than I have ever spent on a toothbrush. Philippa James. 1.Stammers T. Emergency contraception from pharmacists misses opportunity. BMJ 2001; 322: 1245 |
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Trevor Stammers, Tutor in General Practice St. George's Hospital Medical School
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I can reassure Philippa James that I do not object, on the basis of STI risk remaining unaddressed, to pharmacies supplying emergency contraception. I do however want to highlight that an opportunity to reduce the spread of STIs has been largely missed. Whilst I am sorry that James, from the heading of her letter, appears to regard this as an "irrelevance", I am glad to learn that all pharmacies in Manchester are in fact giving out a leaflet on STIs with the emergency pill. Jan Clarke's letter and anecdotal experience locally indicate that this is far from common practice elsewhere. Of course, women requesting a pregnancy test at a pharmacy may be at risk of an STI too, but I doubt that the incidence in this group is as high as the 25% chlamydia positives found among those requesting the emergency pill in Dr. Clarke's audit. The whole point is that a detailed sexual history needs to be taken in order to establish the risk and as Gary Ward concurs "most UK community pharmacies simply do not have the facilities to take history in private" I am indeed aware that screening within 72 hours of the last exposure is futile for chlamydia but as Jan Clarke's figure of 25% positivity confirms, it is previous exposures too that we need to be concerned about with a disease that often gives little in the way of symptoms. Clearly, those requesting EC constitute a high-risk group in this regard overall. I greatly appreciate Bissell's sensitive exploration of some the practical difficulties associated attempting to deal with STIs when the patient's agenda is somewhat different. The universal distribution of a leaflet on STI which can be read at a more "teachable moment" should address my concerns to a large degree and having the Brook's welcome support in this will help greatly to see that it becomes standard practice nationally. |
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Rebekah Cooke, Community Pharmacy Adviser Southern Derbyshire Health Authority
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In response to Trevor Stammers letter we would first say that no-one who is advocating or involved in promoting wider provision of Emergency Hormonal Contraception(EHC)has a "tunnel vision" approach to reducing unplanned pregnancy. Easy availabilty of EHC is only one small but essential part of the jigsaw. The Royal Pharmaceutical Society issued guidelines to pharmacists selling EHC advising on the content of any such consultation including the need wherever possible to inform patients of disease prevention. Whilst these are guidleines only, Pharmacists have a professional responsibility to adhere to them as closely as possible. In Southern Derbyshire we operate a scheme in which accredited Pharmacists can provide EHC free of charge to patients under a patient group direction. The pharmacists involved are obliged to follow a strict protocol which includes giving the women advice on a number of issues including on-going contraception (including details of local FP clinics) and the risk of sexually transmitted diseases. This includes advising them to contact local GUM and FP clinics if they are at high risk. The verbal advice is supported by written details which every patient recieves during the consultation. We strongly support the motion at the BMA conference that EHC should be more widely available as a free service under patient group direction from specifically trained pharmacists, school nurses and health visitors From Rebekah Cooke (DETAILS ABOVE) and Dr Jackie Abrahams Lead Doctor, Family Planning services |
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