Interval to treatment of sexually transmitted infections in adolescent females

Rates of Appropriate Treatment and Follow-Up Testing After a Gonorrhea and/or Chlamydia Infection in an Urban Network of Federally Qualified Health Center Systems

BACKGROUND

Reinfection and partner transmission are common with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT). We assessed treatment and follow-up laboratory testing for GC and CT and evaluated associations with patient- and system-level factors.

METHODS

The analysis included positive GC and/or CT nucleic acid amplification test results from patients aged 14 to 24 years at a federally qualified health center system site in Denver, CO, from January 2018 to December 2019. Outcomes assessed include treatment within 14 days, HIV/syphilis testing within 6 months, and repeat GC and CT testing within 2 to 6 months. Bivariate and multivariable regression modeling assessed associated factors.

RESULTS

Among 27,168 GC/CT nucleic acid amplification tests performed, 1.8% (484) were positive for GC and 7.8% (2125) were positive for CT. Within the assessed time frames, 87% (2275) of patients were treated, 54.1% (1411) had HIV testing, 50.1% (1306) had syphilis testing, and 39.9% (1040) had GC and CT retesting. Older patients were more likely to receive treatment (adjusted odds ratio 1.13; 95% confidence interval, 1.00-1.27; P = 0.05) than younger patients, whereas males were less likely to receive GC and CT retesting (adjusted odds ratio, 0.19; 95% confidence interval, 0.11-0.33; P < 0.001) than females. Patients treated on the day of testing were less likely to receive follow-up laboratory tests than those treated 2 to 14 days after.

CONCLUSIONS

Although most patients received antibiotic treatment, only about half received HIV/syphilis testing and less than half received GC and CT retesting. It is critical to find innovative strategies to improve treatment and follow-up management of these infections to decrease complications, reduce transmission, and combat the rising rates of sexually transmitted infections.

Adolescents Accessing School-Based versus Family Planning Clinics: Chlamydia and Gonorrhea Testing and Treatment Outcomes

Simple Summary

Sexually Transmitted Infections, such as gonorrhea and chlamydia, are common in school-aged youths. These infections can cause significant health problems if not identified and treated early. Current estimates of how widespread these infections are among students receiving healthcare in schools, the role school-based clinics may have in gonorrhea and chlamydia testing and treatment, and information on how the COVID-19 pandemic affected testing and treatment, are lacking. This study was conducted in an urban metropolitan area in the United States, and included 2439 patients aged 13–17 years over a 2-year period. The patients were seen at four school-based and five family planning clinics. We found that 35% of those tested in school-based clinics were positive for chlamydia, and 10% were positive for gonorrhea. The rates of these infections were higher than previous reports from school settings (both pre-COVID-19 and the during COVID-19 pandemic). School-based clinics were able to treat patients with gonorrhea and chlamydia much faster (average ~6 days) than the family planning clinics (average ~18 days). This study shows us the critical role that school-based clinics play in the testing and treatment for gonorrhea and chlamydia infections, and the value of strengthening the services these clinics provide.

Abstract

The prevalence and treatment of chlamydia (CT) and gonorrhea (GC) at school-based clinics (SBCs) requires revisiting. To assess whether clinic type influences CT/GC testing and treatment for minors (individuals 13–17 years of age), our study compared four SBCs with five family planning clinics (FPCs) in the Houston, Harris County metropolitan area of Texas, USA for: (1) the prevalence of CT/GC infection (pre-COVID-19 and during COVID-19); (2) treatment rates at the last positive diagnosis; and (3) the time, in days, from testing-to-diagnosis and testing-to-treatment. Between January 2019 and December 2020, 2439 unique patients (1579 at SBCs, 860 at FPCs) were seen. Of the 1924 tests obtained, 39.2% and 15.9% were positive for CT and GC, respectively. The prevalence of CT and GC at SBCs was similar prior to COVID-19 vs. during the COVID-19 pandemic. SBCs were able to provide treatment significantly faster after diagnosis (mean, 6.07 days; 95% CI, 3.22–8.90; 94.7% were within 30 days) than FPCs (mean, 17.60 days; 95% CI, 10.15–25.12; 84.7% were within 30 days) (p = 0.0257). This comparison within our large clinic system, with consistent clinical management protocols, suggests that SBC care may be critical to ensuring optimal sexually transmitted infection management in minors.

The magnitude of, and factors associated with, loss to follow-up among patients treated for sexually transmitted infections: a multilevel analysis

OBJECTIVES

The loss to follow-up (LTFU) among patients attending care for sexually transmitted infections (STIs) in Sub-Saharan Africa is a major barrier to achieving the goals of the STI prevention and control programme. The objective of this study was to investigate individual- and facility-level factors associated with LTFU among patients treated for STIs in Ethiopia.

METHODS

A prospective cohort study was conducted among patients attending care for STIs in selected facilities from January to June 2015 in the Tigray region of Ethiopia. LTFU was ascertained if a patient did not present in person to the same facility within 7 days of the initial contact. Multilevel logistic regression was used to identify factors associated with LTFU.

RESULTS

Out of 1082 patients, 59.80% (647) were LTFU. The individual-level factors associated with LTFU included having multiple partners (adjusted OR (AOR) 2.89, 95% CI 1.74 to 4.80), being male (AOR 2.23, 95% CI 1.63 to 3.04), having poor knowledge about the means of STI transmission (AOR 2.08, 95% CI 1.53 to 2.82), having college level education (AOR 0.38, 95% CI 0.22 to 0.65), and low perceived stigma (AOR 0.60, 95% CI 0.43 to 0.82). High patient flow (AOR 3.06, 95% CI 1.30 to 7.18) and medium health index score (AOR 2.80, 95% CI 1.28 to 6.13) were facility-level factors associated with LTFU.

CONCLUSIONS

Improving patient retention in STI follow-up care requires focused interventions targeting those who are more likely to be LTFU, particularly patients with multiple partners, male index cases and patients attending facilities with high patient flow.

Online chlamydia testing: an innovative approach that appeals to young people

OBJECTIVE

To evaluate data from an online chlamydia testing program (OLC) developed to increase young people's access to testing for chlamydia, the most commonly notified disease in Australia and Western Australia, with a high proportion of notifications among young people (< 30 years).

DESIGN AND SETTING

The OLC was launched in February 2010, and our study covers the period February 2010 to June 2011. Without needing to first visit a doctor, OLC participants receive risk self-assessment, education, testing, and, if necessary, referral for treatment, and can complete an online satisfaction survey.

MAIN OUTCOME MEASURES

Number and proportion of downloaded pathology forms that resulted in a test; demographic characteristics of participants; prevalence of chlamydia; completeness and timeliness of follow-up of positive test results; and participant satisfaction.

RESULTS

More than half (56%) of the 675 OLC pathology form downloads resulted in a test, and chlamydia was detected in 18% (66/377). Of those tested, over half were men (55%), and 71% were aged < 30 years. All participants with a positive test result received appropriate clinical management, with 50% being treated within 7 days of specimen collection. Of the 17% (55/332) who completed an online satisfaction survey, almost all said they would recommend the service to a friend.

CONCLUSION

Internet-based screening for chlamydia is an effective means of increasing access to testing for young people at risk of sexually transmitted infections and is a valuable addition to opportunistic, clinic-based strategies.

Improving notification of sexually transmitted infections: a quality improvement project and planned experiment

BACKGROUND AND OBJECTIVE

Inadequate follow-up of positive sexually transmitted infection (STI) test results is a gap in health care quality that contributes to the epidemic of STIs in adolescent women. The goal of this study was to improve our ability to contact adolescent women with positive STI test results after an emergency department visit.

METHODS

We conducted an interventional quality improvement project at a pediatric emergency department. Phase 1 included plan-do-study-act cycles to test interventions such as provider education and system changes. Phase 2 was a planned experiment studying 2 interventions (study cell phone and patient activation card), using a 2 × 2 factorial design with 1 background variable and 2 replications. Outcomes were: (1) the proportion of women aged 14 to 21 years with STI testing whose confidential telephone number was documented in the electronic medical record; (2) the proportion of STI positive women successfully contacted within 7 days.

RESULTS

Phase 1 interventions increased the proportion of records with a confidential number from 24% to 58% and the proportion contacted from 45% to 65%, and decreased loss to follow-up from 40% to 24%. In phase 2, the proportion contacted decreased after the electronic medical record system changed and recording of the confidential number decreased. Study interventions (patient activation card and study cell phone) had a synergistic effect on successful contact, especially when confidential numbers were less reliably documented.

CONCLUSIONS

Feasible and sustainable interventions such as improved documentation of a confidential number worked synergistically to increase our ability to successfully contact adolescent women with their STI test results.

Using a rapid communication approach to improve a POC Chlamydia test

Chlamydia trachomatis is a common sexually transmitted infection in young women. Available point-of-care (POC) diagnostic tests perform poorly, but development of new devices can be costly and time consuming. We explored the feasibility (user friendliness) and test characteristics (sensitivity and specificity) of a new prototype device to detect Chlamydia in adolescent women by using small numbers of subjects and rapid communication with the manufacturer. We compared cervical POC test results to the gold standard (cervical nucleic acid amplification testing). We also assessed the accuracy of the POC test on self-collected vaginal swabs by comparing results to cervical nucleic acid amplification test and to the cervical POC test. We frequently reviewed user experience and test results with the manufacturer. The results showed the feasibility and accuracy of the device. Feasibility--initial device malfunctions were identified and corrected. This device would be easy to use in a nonclinical setting, as it is self-contained and the color change for some specimens was dramatic and immediate. Accuracy--initial prototypes demonstrated low sensitivities (38%) for vaginal and cervical swabs. After feedback, the company developed new prototypes with improved sensitivity (80%). However, the increased sensitivity was accompanied by a high percentage of indeterminate results and false positives that lowered specificity.

Point-of-care testing for sexually transmitted infections increases awareness and short-term abstinence in adolescent women

PURPOSE

To evaluate the effect of point-of-care (POC) testing for sexually transmitted infections (STIs) on reported awareness of test results and STI risk-reduction behaviors in adolescents.

METHODS

Adolescent and young adult women aged 14-21 years were recruited from the Emergency Department or Teen Health Clinic for this longitudinal study and were tested for STIs. Baseline demographics, risk behaviors, treatment, POC tests (wet mount and rapid antigen tests for Trichomonas vaginalis), and other STI test results (available 24-48 hours postvisit) were measured. These were compared to subject's report of test results, abstinence, partner discussion, and partner testing during a postvisit telephone contact.

RESULTS

Of 294 subjects, 155 (53%) were contacted: 65 (42%) had a positive STI test result; 28 (43%) were POC positive; and 52 (33.5%) believed their STI results were positive. A positive POC test result increased the proportion of subjects aware of being positive for an STI (89 vs 21%, p < .01). Postvisit, 62% reported abstinence, 82% discussed testing with her partner, and 48% reported partner testing. Predictors of abstinence included a positive POC test result (adjusted odds ratio (AOR) = 4.6, confidence interval (CI) = 1.5-13.6, prior abstinence of >14 days (AOR = 3.9, CI = 1.7-9.0), and black race (AOR = 3.5, CI = 1.2-9.7). Women who believed their STI results were positive were more likely to report partner discussion (odds ratio [OR] = 3.0, CI = 1.0-8.8) and partner testing (OR = 5.1, CI = 2.4-11.2).

CONCLUSIONS

Awareness of STI results increases with POC testing. Effective communication of results can increase patient understanding and compliance with risk reduction strategies, which may affect the STI epidemic.

Suboptimal therapy and clinical management of gonorrhoea in an area with high-level antimicrobial resistance

The choice of antimicrobial agents for the treatment of gonorrhoea is critical in areas where the prevalence of drug resistance is high. This study aimed to evaluate the antibiotic treatment of gonorrhoea in endemic areas. During 1999-2004, all Neisseria gonorrhoeae infections (n = 90) were evaluated. Patients' medical records and antibiotic treatment regimens were retrospectively reviewed if their isolates were viable (n = 65). In vitro antimicrobial susceptibility of N. gonorrhoeae isolates was performed. Urethritis (89%) and pelvic inflammatory disease (42%) were the most common presentations among men (n = 53) and women (n = 12), respectively. Of 54 patients with uncomplicated N. gonorrhoeae infection, 32 of them received appropriate antibiotics, including cefuroxime (n = 20), ceftriaxone (n = 10), ciprofloxacin (n = 1) and azithromycin (n = 1) during follow-ups. Among 65 patients, 53.8% were notified to the health authority. Check-ups of other sexually transmitted diseases were carried out in only 46% of patients. Not all isolates were susceptible to penicillin, 96.9% were resistant to tetracycline and 86% were resistant to ciprofloxacin. Ceftriaxone, cefixime, spectinomycin and azithromycin were active in vitro against all isolates. In conclusion, It is crucial to develop treatment guidelines according to regional antimicrobial resistances and educational programmes to improve clinical care for genital gonococcal diseases.