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ss nucleus - summer 2005,  Chlamydia screening - Britain forward not back?

Chlamydia screening - Britain forward not back?

Gavin Ling ponders whether chlamydia screening is a good thing

Sexually transmitted infections (STIs) have always been a blight on society through the years. In this decade, chlamydia is a serious problem affecting both men and women; it is now the most common STI. Although it can be asymptomatic in up to 70% of cases in women, 10-30% develop pelvic inflammatory disease (PID) as a result and infertility may ensue. In men, it can also cause epididymo-orchitis. Public health doctors are clamouring for the introduction of a genuine nation-wide screening programme: in 2004 the British Medical Association (BMA) conference in public health medicine passed a unanimous motion calling for implementation as soon as possible.[1]

The government had already been developing the National Chlamydia Screening Programme (NCSP) in 2002, available free on the National Health Service (NHS), following pilots done in Portsmouth and the Wirral. Currently, about 25% of primary care trusts have the facility to screen for the disease on demand, and conduct opportunistic tests for all under-25s who are sexually active. The programme is a veritable smorgasbord: the cover is patchy in GP surgeries, genito-urinary medicine clinics and family planning clinics as well as non-health venues. The tests vary too, from urine sampling to ‘swab it yourself’ sticks. If a person tests positive, the aim is to treat them and encourage them to notify their partners, according to the NCSP in England Programme Overview.[2]

From a pragmatic perspective, it is not difficult to see the advantages of chlamydia screening. If chlamydia is found in one in ten screened, then there may be a huge future burden on the NHS through demands for IVF – not a low-cost procedure, financially or emotionally. By comparison, a quick test and a short course of antibiotics would seem cheaper in the long run for the NHS. The programme would be, in theory, a further step in the direction of giving women the ability to have sex (outside the context of marriage) without any physical consequences.

A critique on the current programme

Clearly some form of effective screening is a desirable goal, particularly in light of the soaring rates of STIs. Where research and therapies are carried out in an ethical fashion, Christians should encourage the use of new technologies and advances, rather than sit with our arms folded and try to make people believe that we genuinely are ‘caring’.

However, where the existing policy is morally inappropriate or has no evidence base, Christians should speak out. Chris Richards, a consultant paediatrician, recently wrote in Triple Helix condemning the lack of human interaction in the process, ultimately removing the moral element from medicine.[3] Opportunistic screening for chlamydia has distinct disadvantages: the scheme will not be accessible to people who never turn up to any health centres or youth venues. A study published in the BMJ in April 2005 investigated postal screening for chlamydia, and commented on opportunistic screening. It came up with few surprises, showing that having one or more partners in the last twelve months was the strongest predictor of infection; but it did solidify evidence against a poor UK programme. The authors stated that those least likely to participate in screening were exactly those who were most likely to have the disease: those in deprived areas, under-25s and non-whites. The youngest age groups (under-25s) needed repeated contacts to convince them to participate in the study. Questioning the usefulness of their own efforts, the authors admitted that postal screening was feasible, but that it was difficult to achieve high response rates;[4] it seems that anonymity provides little benefit.

The paper in its conclusion found that, ‘evidence for the long term effectiveness and impact of chlamydia screening programmes remains limited.’ Equally, in a revealing assessment, the authors claimed, ‘this approach…has not controlled transmission in Sweden’, where a similar setup exists.

God’s judgment: interfere not?

Even while conversations about sex are no longer considered embarrassing, talking about STIs or getting one is taboo. Having sat in sexual health clinics before as a student, the embarrassment of some patients is palpable. Most in the waiting area are hunched over various types of reading material or talking with their boy/girlfriend in hushed tones: could it be that there is an implicit awareness that they shouldn’t be there in the first place?

In Paul’s letter to the Romans, he is clear about God’s judgment on the people of this world.[5] Mankind chooses to deny God, even though they are aware of him. Part of the present judgment is to give them over to their sin, and allow them to commit whatever acts they please. The punishment is that the world thinks less and less of God, which will, at the final judgment, bring about a terrible conclusion.

One possible interpretation is that we, as Christians, should leave people to reap the consequences of sexual infection. By logical implication, if we are to sit in judgment on such cases, doctors would be unable to treat conditions caused by lifestyle choices, such as smoker-related illnesses, diabetics with poor glucose control – the list would be endless. The apostle Paul takes a dim view of this attitude: he reminds us that we are all guilty before God and that none of us have reason to boast;[6] as members of God’s household following his rules, we must remain pure, but at the same time, not judge the world.[7] We should be content to leave God as sovereign on matters of judgment, yet have compassion, as Jesus did, on those who fall into sin.

Wider concerns about STI treatment

Chlamydia screening per se is not a bad development; the context in which it is deployed makes it of questionable value. The current policy fails to tackle causes and paradoxically introduces complacency and even more risk-taking activity (for example, studies have shown that with the emergence of anti-retroviral therapy, HIV is no longer treated as a serious disease and has resulted in an increase in ‘unsafe’ sex).[8] By contrast, in dealing with STIs, especially AIDS, Uganda has a particularly promising programme of ABC (Abstain, Be faithful, use Condoms), which has seen infection rates fall dramatically to one-third of their previous level between 1991 and 2001.

Without speaking of the values of abstinence (which is 100% effective) and fidelity in the fight against STIs, it is like suggesting to patients with ischaemic heart disease that they needn’t consider lifestyle changes and rely solely on medical therapy instead. It is good that this country is coming to terms with a sexual infection epidemic, but it’s a shame that we are tackling it in the wrong way. When all the authorities are providing is a simple ‘screen and treat’, a halfway house for chlamydia may be more harmful than none at all: it’s probably worth putting the taxpayers’ pounds somewhere else.

Further reading

  1. Coombes R. Doctors demand national screening for chlamydia. BMJ 2004;328:1397
  3. Richards C. Chlamydia screening at Boots: demoralising medicine. Triple Helix 2005; Spring:3
  4. Macleod J et al. Coverage and uptake of systematic postal screening for genital Chlamydia trachomatis and prevalence of infection in the United Kingdom general population. BMJ 2005;330:940
  5. Rom 1:18-31
  6. Rom 2:1-4
  7. 1 Cor 5:12,13
  8. Gremy I, Beltzer N. HIV risk and condom use in the adult heterosexual population in France between 1992 and 2001: return to the starting point. AIDS 2004;18(5):805-809
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