STI screening and management — structured oral station (12 minutes)

Opening prompt — "She has postcoital bleeding and a discharge. What is the first thing you do?"

Model response: ^[1][2]

• "PCB with a mucopurulent discharge is cervicitis until proven otherwise — most commonly chlamydia or gonorrhoea, but I must run the full STI panel, not a single test."
• "I exclude pregnancy first with a urine beta-hCG, then perform a speculum examination to visualise the cervix, take a chlamydia and gonorrhoea NAAT (self-collected vaginal swab or endocervical), and send the full panel: syphilis serology, HIV, hepatitis B surface antigen and core antibody, hepatitis C antibody, and a cervical screen (HPV plus LBC) if due."^[1][2]

Probe 1 — "Chlamydia is positive. What do you prescribe?"

• "First-line treatment for uncomplicated genital chlamydia in a non-pregnant adult is doxycycline 100 mg orally twice daily for 7 days. Doxycycline is now preferred over azithromycin because the CHLAZIDOXY trial and systematic reviews showed it outperforms azithromycin for anorectal chlamydia in women, which is common and often unrecognised."^[1][4]
• "If she were pregnant, I would switch to azithromycin 1 g orally as a single dose, because doxycycline is contraindicated in pregnancy owing to fetal tooth discoloration."^[1]
• "I would also test for HIV and other STIs if not done, offer PrEP counselling if appropriate, and notify the state health department of the diagnosis."^[1]

Probe 2 — "How do you handle partner notification?"

Communication and respect domains — demonstrate it out loud: ^[1][3]

• "The diagnosing doctor — me — is responsible for initiating and documenting the partner notification discussion in this consultation."
• "I counsel her that untreated partners will reinfect her and may pass it on. I give her three options: patient referral (she tells them), provider referral (the clinic contacts them without naming her), or patient-delivered partner therapy — PDPT is approved in Victoria, NSW and the NT for heterosexual patients with anogenital chlamydia where partners are unlikely to attend."
• "The chlamydia trace-back window is at least 6 months, or to the last negative test. I document the discussion, the contacts identified, and the chosen strategy."^[1][3]

Probe 3 — "She is frightened. How do you counsel her?"

• Move to her eye level, use her name, normalise the consultation: "STIs are common, treatable and most often completely curable. We will treat you today, support you to tell your partner in a way that works for you, and bring you back in three months for a retest to be sure the infection is gone and you have not been reinfected."
• Offer a written factsheet and a named clinic contact for between visits.^[1]

Probe 4 — "Syphilis serology comes back reactive with an RPR of 1:32. How does that change the plan?"

• "A reactive treponemal test confirms past or present infection; the RPR titre of 1:32 is high and consistent with early infectious syphilis. I would treat her for early syphilis (primary, secondary or early latent — depending on the history and examination) with benzathine benzylpenicillin 2.4 million units intramuscularly as a single dose, given as two injections of 1.2 MU each."^[1]
• "I would warn her about the Jarisch-Herxheimer reaction — fever, malaise, rigors 6 to 12 hours after treatment. I would not switch to doxycycline unless she had a confirmed penicillin allergy and was not pregnant; in pregnancy, the rule is penicillin only."^[1]
• "Repeat RPR at 3, 6 and 12 months. A four-fold drop (1:32 to 1:8) by 6 months indicates adequate response."^[1]

Probe 5 — "She is pregnant. Does anything change?"

• "Yes — everything changes. Switch the chlamydia regimen to azithromycin 1 g PO stat. For syphilis, treat with benzathine penicillin as for the non-pregnant by stage; only penicillin treats the fetus — desensitise and treat if penicillin-allergic. Consider overnight admission for the first dose beyond 20 weeks because of the Jarisch-Herxheimer risk to the fetus, and arrange fetal monitoring. Repeat syphilis serology in the third trimester and at delivery."^[1]