Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.
Rapid STI diagnosis
I attended a lunch session sponsored by Cepheid regarding rapid STI diagnosis and use of point of care testing.
Working primarily in an Indigenous health setting in North Queensland I wanted to see whether a point of care testing model might be helpful with our patient cohort.
Dr Jeff Klausner started the session off presenting `Utility and applications of rapid, molecular STI testing in hard to reach populations´. The current STI statistics globally are quite staggering; over one million new STIs are acquired globally every day and each year there are 357 million new curable STIs ( CT/NG/TV and syphilis). There is the rising risk of untreatable gonorrhoea, so much so that the WHO has listed NG as one of the top 3 infections that require immediate action. CDC reports demonstrate that STIS are increasing for the first time since 2006 and CDC STI guidelines indicate that treatment needs to be provided on the same day and directly observed.
Point of care STI testing clearly has demonstrated merit. For the patient it provides decreased anxiety and less patients are lost to follow-up. From a public health perspective there is decreased risk of forward transmission of infection, faster treatment for patients and their partners and decreased antimicrobial resistance. From an economic point of view there is scope to expand clinic capabilities, improve treatment costs and target individualized (rather than empiric) treatment. This was illustrated in the example of the Dean Street Express clinic in London. With the use of PoC testing there is quicker treatment, decreased waiting times and increased testing.
Dr Klausner discussed the rates of STIs in pregnancy and the negative consequences of STIs in pregnancy including miscarriage, stillbirth, preterm labour, low birth weights and increased MTCT of HIV. Currently only 13 countries in the world require routine chlamydia testing despite these known adverse outcomes. Point of care testing was trialled in 7 low-middle income countries and more than 2,200 pregnant women were screened for CT, NG and TV. The result of this trial showed high acceptability amongst patients and high treatment rates.
Dr Basil Donovan went on to discuss ´Implementing molecular POC testing in remote primary care in Australia´. Dr Donovan illustrated the difficulties of health care in remote Indigenous communities including the distance from laboratories, high mobility of the population, delays in time to treatment, high rates of PID and disseminated NG.
The Test, Treat and Go Trial was discussed (TTANGO). This was a cross over randomised controlled trial that compared traditional laboratory testing with point of care testing in a number of remote locations across Australia. Median time to treatment was 0 days for POC testing versus 7 days for laboratory testing. Patients reported that they liked getting their result on the same day, that they could be treated on the same day and that they didnt have to return for follow-up. The patient reported dislikes were that they didnt like ´waiting around´. Staff were also interviewed and expressed that they ´felt like a scientist at times´. The staff reported that the point of care tests were easy to use and interpret and they felt increased job satisfaction. Of course there are challenges to report which included high staff turnover in these communities, the need for ongoing public health surveillance and adapting clinical practice.
The session in my opinion was very useful and insightful and very relevant to my current clinical practice. At the particular indigenous health clinic I work at we have high rates of STIs, high rates of treating emperically and difficulty with follow-up. Point of care testing (if costs are appropriate) may be an option for our clinic to improve treatment rates and appropriate use of antimicrobials.