Rhetoric and reality in person-centred care: introducing the House of Care framework.

We would like to follow up the recent editorial entitled ‘Safer “chemsex”’ by Ma and Perera1 by including sexually transmissible enteric infections (STEI) among the pathogens whose transmission may be associated with chemsex. Shigella, which causes a range of gastrointestinal symptoms in humans,2 is the primary example here, although verocytotoxinproducing Escherichia coli has also been described.3 Until recently, Shigella infections in England were primarily associated with travel to endemic areas. However, in the past decade, a Shigella epidemic has been documented in men who have not travelled, thought due to faecal–oral transmission during sex, in men who have sex with men (MSM).4 Chemsex may influence willingness to engage in sexual practices that increase the risk of faecal–oral transmission.5 Gilbart and colleagues5 reported an investigation into a Shigella case series in adult males between 2012 and 2013. Of 42 patients interviewed, 34 were MSM, many of whom were HIV positive, and who reported multi-partner condomless sex at sex parties and chemsex. Importantly, more than half first presented to their GP, emphasising the importance of increasing understanding about this epidemic both within and outside of specialised sexual health clinics. In the event of a diagnosis of Shigella and no recent travel to an endemic area, we recommend sensitively ascertaining a sexual history from men, particularly in London, Brighton, and Manchester, where we know Shigella transmission is high among MSM. If a patient with Shigella reports same-sex partners, this should prompt discussion of referral to sexual health services as these patients are likely to be at risk of STIs and HIV co-infection. Providing information on avoidance of sex until a week after symptom cessation, on condom use, and on reducing risk of exposure through oral–anal contact is also important.6 If the patient presents with infectious bloody diarrhoea there is a duty to notify the health protection team.7 Manpreet Bains, GP Trainee & National Medical Director’s Clinical Fellow, Public Health England. E-mail: [email protected]