Are clinicians open to less asymptomatic STI screening for chlamydia and gonorrhoea in gay, bisexual and other men who have sex with men and the possibility of not treating positive diagnoses? A qualitative study from Australia

Evidence from real-world studies suggests that 3-monthly screening for asymptomatic chlamydia/gonorrhoea is not reducing incidence and is driving increased antibiotic use and antimicrobial resistance (AMR). While some countries are recommending less screening, changes to guidelines require clinician buy-in. This study explored the views of Australian sexual health clinicians to changing practices around asymptomatic screening for chlamydia/gonorrhoea in gay, bisexual and other men-who-have-sex-with-men (GBMSM) and attitudes to not automatically treating positive diagnoses. We conducted thematic analysis of 16 semi-structured interviews with clinicians working in a range of settings. Interviews covered: evidence on test and treat, perspectives on reducing screening and treatment for chlamydia/gonorrhoea in GBMSM, AMR, and managing patient conversations. Clinicians had variable knowledge about the limited effectiveness of asymptomatic screening. Many were open to reduced screening, if provided supporting evidence. Given challenges in reducing medical interventions, they recommended public education to drive changes. While some clinicians supported patient dialogue in treatment decision-making, most felt uncomfortable not treating. Concerns included: ideas about their role as doctors; onward transmission (particularly to women); and, complications/uncomfortable symptoms/patient psychological well-being. AMR considerations were less salient. While the test and treat paradigm is engrained, clinicians were open to reduced screening, if provided with clear evidence, but were generally reluctant to not treat. A flexible approach that supports patient empowerment in decision-making about screening frequency and choices around treatment could present a way forward. Changing practice requires education to shift patient/clinician mindsets around what it means to have a positive chlamydia/gonorrhoea diagnosis.