Sample policy · Sexual health

STI testing, results and PrEP policy (sexual health)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The clinical standards governing STI testing and PrEP sit in BASHH, BHIVA and UKHSA guidance, which are the real primary sources for the clinical content; this policy operationalises Regulation 12 around them. · primary source

1. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b))

ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c))

the proper and safe management of medicines, (Reg 12(2)(g))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations. For a sexual health service, the biggest safety risk is a test result that is not acted on, above all a reactive HIV or syphilis result that is missed or delayed, so this policy builds a fail-safe around every result and around PrEP monitoring.

3. Purpose

A sexual health service tests for infection, gives results, treats, and offers HIV prevention. The biggest safety risk is a result that is not acted on, above all a reactive HIV or syphilis result that is missed or delayed. This policy sets out how the Service tests appropriately, makes sure every result is seen and acted on, treats and refers correctly, and runs PrEP safely.

The Service must verify this policy against current BASHH testing guidance and the BHIVA/BASHH PrEP guidelines before adoption.

4. Scope

This policy applies to:

Where a patient is under 18, or where capacity to consent is in question, the Service applies Fraser guidelines and Gillick competence, the Mental Capacity Act 2005 where relevant, and the local safeguarding children procedures under Working Together to Safeguard Children 2026 (see the under-18s and consent provisions of the relevant policies).

5. Testing

6. Results: the fail-safe

Every test result is seen and acted on. The Service:

7. Treatment and onward referral

8. PrEP

Where the Service provides HIV pre-exposure prophylaxis:

9. Recording

The Service records the tests done, the results, the treatment given, referrals made, PrEP assessments and monitoring, and the communication with the patient, all in line with the confidentiality policy.

Operational controls to adapt

Roles and responsibilities

Testing, results and PrEP procedure

  1. Record the testing indication. The clinician records symptoms, exposure, risk, screening reason, window-period advice and tests requested.
  2. Track every sample sent. Each sample has a lab reference, expected result date, responsible owner and chase date if no result arrives.
  3. Review results daily. The results owner actions normal, positive, reactive, inconclusive and rejected samples, and does not leave results unallocated.
  4. Escalate urgent results. Reactive HIV, syphilis, hepatitis, high-risk infection, pregnancy-related concern or safeguarding concern is escalated to the clinical lead the same day it is reviewed.
  5. Contact safely. Patient contact follows the recorded confidentiality preference. Failed contact attempts are logged and escalated according to risk.
  6. Complete treatment or referral. Positive results are linked to treatment, test of cure, onward referral, partner notification and notifiable-infection reporting where required.
  7. Control PrEP prescribing. PrEP is not started without a documented negative HIV result and baseline checks. Continuation is held or reviewed where required monitoring is overdue.
  8. Close the loop. A case is not closed until the result, action, patient communication, treatment or referral, and follow-up plan are all recorded.

Records and register links

The testing and PrEP record should include:

Missing results, delayed reactive-result action, incorrect patient contact, PrEP monitoring gaps and repeated lab or booking failures are opened on the relevant register.

10. Training

Clinicians who test, treat and prescribe PrEP keep current with the guidance and are competent for what they do; staff who manage results are trained in the fail-safe and confidentiality. The Service records who is competent and the next refresher date.

11. Audit cadence

The Service checks, on a stated cadence, that:

The Registered Manager and the clinical lead review the results and record the improvement actions that follow.

12. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

Original sources carried forward from this policy:

Source-pack stack for STI testing / PrEP (sexual health):

Related reading

13. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

14. Document control

Version Date Author Changes
v1.1 2026-07-14 Verivius (sample) Added role ownership, results fail-safe controls, PrEP monitoring records, register links and related reading.
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard, additively: added statutory anchor, verbatim Regulation 12 quotes, plain-English summary, under-18s/Fraser scope note, and the source-pack stack. All original sections and source URLs preserved.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

The specific danger this policy guards against is a reactive result that nobody acts on. A person can leave an appointment feeling reassured while carrying an HIV or syphilis infection, and if the result comes back reactive and no fail-safe catches it, the first anyone hears of it may be when they are seriously unwell or have passed it on. The same logic runs through PrEP: prevention meant for an HIV-negative person, started on an unconfirmed status or continued while monitoring lapses, can mask a seroconversion and let a treatable infection progress unseen. What protects the person is not the test itself but the trail around it: the sample tracked to its result and its action, the reactive result escalated and the person reached through a route that does not out them at home, the confirmed baseline before PrEP, and the monitoring that keeps it safe. Because so much of the harm here is silent, the record that shows the loop closed is the only thing that can tell, later, a result that was acted on from one that fell through.

  1. Every test sent is tracked until its result is back and acted on, and a result that does not arrive is chased rather than assumed negative, so a reactive HIV or syphilis result cannot fall quietly out of the system.

    Strong evidence: The outstanding-results log and results fail-safe (section 6): each sample carrying a lab reference, expected result date, named owner and chase date, with the results owner and deputy reviewing incoming results each working day, held against the audit-cadence check (section 11) that every result was tracked, seen and acted on with none outstanding unnoticed.

    Weak evidence: A results process that relies on the lab ringing if something is wrong, with no log of what was sent and nothing that flags a sample whose result never came back, so an unreturned reactive result reads on paper exactly like a negative. Also weak: an outstanding-results list nobody owns over annual leave, samples left unallocated after review, or a fail-safe the policy describes that no record shows anyone actually runs. The duty to assess and mitigate the risk is statutory; the log fields, chase dates and daily review are the Verivius operational form of it, not a prescribed statutory process.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 12(1) and reg 12(2)(a)-(b)

  2. A reactive or positive result, above all HIV or syphilis, triggers prompt, sensitive action, and the person is contacted only through the route they agreed, so the news reaches them without revealing the diagnosis to a partner or family member at home.

    Strong evidence: The result record showing the reactive result escalated to the clinical lead, the action taken, and contact made through the recorded confidentiality preference, with failed contact attempts logged and escalated by risk (section 6, procedure steps 4 and 5); the audit-cadence check that reactive results were handled promptly and sensitively.

    Weak evidence: A voicemail or text that names the service left on a shared phone, or a results letter sent to an address the person never confirmed was safe, so a partner learns of the attendance before the person does. Weak too where a reactive result was escalated by word of mouth and the trail stops there, with no record of who was told, when, or what was done, and where a failed contact attempt was logged once and never followed up, leaving a person with an untreated, transmissible infection uncontacted.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. The person consents to what is being tested for, including HIV, and is told what the tests can and cannot yet detect, so someone tested inside a window period leaves knowing a repeat test may be needed rather than falsely reassured by a negative.

    Strong evidence: The testing record: indication, consent to testing including HIV, the sample set, and the window-period advice given with any repeat-test date (section 5, procedure step 1, Records and register links); the audit-cadence check that testing matched risk and the person was told about window periods and consented, including to HIV testing.

    Weak evidence: A consent field carrying identical 'consent given' wording across a run of records, or an HIV test sent with nothing to show the person agreed to it specifically. Weak too where a negative result was handed over as an all-clear with no note that the exposure fell inside a window period, so no repeat was arranged and a recent infection was missed.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  4. PrEP is started only on a documented negative HIV result with the baseline checks done, and never on an unconfirmed HIV status, so a person with an undiagnosed infection is not put on prevention meant for someone who is HIV negative.

    Strong evidence: The PrEP record: baseline HIV status confirmed negative, renal function and any hepatitis checks, and the eligibility and prescribing decision, all dated before the first prescription (section 8, procedure step 7, Records and register links); the audit-cadence check that PrEP had baseline testing before starting.

    Weak evidence: A PrEP prescription dated before, or on the same day as, a baseline HIV test whose result is not yet back, or a baseline HIV entry left blank or marked 'assumed negative on history'. Weak too where eligibility and counselling are recorded but the confirmed baseline result is nowhere on file, so nobody can show the person was HIV negative when PrEP began.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  5. Ongoing HIV and renal monitoring runs to the current guidance and is tracked with the same fail-safe as any other result, and PrEP is held or reviewed when monitoring falls overdue rather than continued on trust.

    Strong evidence: The PrEP monitoring record: the next monitoring date, tracked results, and any hold, stop, restart or specialist-advice decision (section 8, Records and register links), against the audit-cadence check that no PrEP was continued on overdue monitoring; the intervals themselves are set by the BHIVA and BASHH PrEP guidance the policy names, which is the source of the cadence, not this card.

    Weak evidence: A repeat PrEP prescription issued while the monitoring bloods are overdue, with the continuation approved as routine, or a next-monitoring date that has drifted with nothing flagging it. Weak too where monitoring results come back but sit unreviewed outside the results fail-safe, so a seroconversion on PrEP is not caught. No monitoring interval is stated here; that value lives in the guidance the policy names.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  6. An infection is treated to current guidance with a test of cure where indicated, a new HIV diagnosis is referred promptly with the person supported through the handover, and partner notification is offered and kept distinct from notifiable-infection reporting and from a safeguarding referral, because none discharges another.

    Strong evidence: The treatment and referral record: treatment given, test of cure where indicated, onward referral with the person supported through the handover, the partner-notification trigger, and any notifiable-infection report recorded on its own footing (section 7, procedure steps 6 to 8, Records and register links).

    Weak evidence: A positive result linked to a prescription but no test of cure where the guidance expects one, or a new HIV diagnosis referred with no record that the person was supported through the handover, so they are left holding the diagnosis alone. Weak too where partner notification is treated as having covered a notifiable-infection report, or a safeguarding concern in an under-18 attendance is folded into the same line, so a duty owed to a different body is quietly assumed to be done.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

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Last verified 23 July 2026

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Last reviewed 10 June 2026