Home versus clinic-based specimen collection for Chlamydia trachomatis and Neisseria gonorrhoeae

2025 European guideline on the management of Chlamydia trachomatis infections

Sexually transmitted Chlamydia trachomatis infections remain common globally and most frequently are asymptomatic. The 2025 European C. trachomatis guideline provides up-to-date guidance regarding indications for testing and treatment of C. trachomatis infections. It includes advice on urogenital and extragenital C. trachomatis testing including the use of self-collected specimens; recommendation to use only validated NAATs for diagnosis; and recommendation to treat all C. trachomatis infections with doxycycline as first line in preference to single-dose azithromycin regimens. The absence of evidence and limited value of broad screening in asymptomatic populations for C. trachomatis infections is also discussed.

Chlamydia trachomatis as a Current Health Problem: Challenges and Opportunities

Chlamydia is one of the most common sexually transmitted bacterial infections (STIs) worldwide. It is caused by Chlamydia trachomatis (CT), which is an obligate intracellular bacterium. In some cases, it can occur in coinfection with other parasites, increasing the pathologic potential of the infection. The treatment is based on antibiotic prescription; notwithstanding, the infection is mostly asymptomatic, which increases the risk of transmission. Therefore, some countries have implemented Chlamydia Screening Programs in order to detect undiagnosed infections. However, in Portugal, there is no CT screening plan within the National Health Service. There is no awareness in the general healthcare about the true magnitude of this issue because most of the methods used are not Nucleic Acid Amplification Technology-based and, therefore, lack sensitivity, resulting in underreporting infection cases. CT infections are also associated with possible long-term severe injuries. In detail, persistent infection triggers an inflammatory milieu and can be related to severe sequels, such as infertility. This infection could also trigger gynecologic tumors in women, evidencing the urgent need for cost-effective screening programs worldwide in order to detect and treat these individuals adequately. In this review, we have focused on the success of an implemented screening program that has been reported in the literature, the efforts made concerning the vaccine discovery, and what is known regarding CT infection. This review supports the need for further fundamental studies in this area in order to eradicate this infection and we also suggest the implementation of a Chlamydia Screening Program in Portugal.

Comparison of Different Self-Sampling Devices for Molecular Detection of Human Papillomavirus (HPV) and Other Sexually Transmitted Infections (STIs): A Pilot Study

Background: Cervical cancer is the fourth most common cancer in women, and it is well known that high-risk human papillomavirus (hrHPV) infections are the necessary carcinogenic factors for the development of cervical tumors. Moreover, the interaction between HPV and other sexually transmitted infections (STIs) may increase the risk of cancer progression. Self-sampling has been demonstrated to represent a valid and well-accepted alternative, favoring women’s participation in screening programs. This study aimed to investigate the use of FLOQSwabs^® (FS) as compared to two other vaginal self-collection devices for the detection of hrHPV and other sexually transmitted infections. Methods: Cervical and vaginal self-samples were collected, using two different combinations of vaginal self-sampling devices, from 40 women referred to colposcopy for a documented abnormal Pap smear. All samples were tested for hrHPV and seven STI pathogens using two commercial molecular assays. Results: Data on hrHPV detection from the first group of women showed an almost perfect agreement (kappa: 0.89) between cervical vs. FS vaginal self-samples, and a substantial agreement (kappa: 0.79) between cervical and HerSwab™ (HS) samples. In the second group of women, an almost perfect agreement (kappa: 0.90) was demonstrated in the detection of hrHPV between cervical samples vs. FS, and a moderate agreement (kappa: 0.60) for cervical vs. Evalyn^®Brush (EB) self-collected samples. STI detections showed a very good agreement (kappa: 0.89 and kappa: 1.00) both among FS vs. HS and FS vs. EB, respectively. There was no statistically significant difference between the different devices used. The most frequently detected hrHPV genotypes in the studied population were HPV 16, 31, 35, 51, and 56; whilst the most frequently identified STI pathogens were Ureaplasma parvum and Mycoplasma hominis. Overall, investigated women did not report any discomfort in using the different vaginal self-collection devices. Conclusion: Evaluation of the three different vaginal self-collection devices confirmed their overall good acceptability by the studied population, as well as a similar agreement for hrHPV detection as compared to cervical samples. Our study indicated that the use of self-collected samples offers an alternative strategy to improve women’s participation in cervical cancer screening programs, but also underlined the importance of evaluating the concordance in hrHPV detection of collection devices in combination with the molecular hrHPV assay.

Copan Walk Away Specimen Processor (WASP) Automated System for Pathogen Detection in Female Reproductive Tract Specimens

Objective

Automation is increasingly being applied in clinical laboratories; however, preanalytical processing for microbiology tests and screening is still largely performed using manual methods owing to the complex procedures involved. To promote automation of clinical microbiology laboratories, it is important to assess the performance of automated systems for different specimen types separately. Therefore, the aim of this study was to explore the potential clinical application of the Copan Walk Away Specimen Processor (WASP) automated preanalytical microbiology processing system in the detection of pathogens in female reproductive tract specimens and its feasibility in optimizing diagnostic procedures.

Methods

Female reproductive tract specimens collected from pregnant women at their first obstetric check-up were inoculated into culture media using the Copan WASP automated specimen processing system and were also cultured using a conventional manual inoculation method. After 48 h of culture, the growth of colonies was observed, and the types of bacteria, number of colonies, and efficiency in isolating single colonies were compared between the automated and manual groups. The specimens collected from the WASP system using the Copan-ESwab sample collection tubes were further analyzed for the presence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Ureaplasmaurealyticum (UU) via fluorescence quantitative polymerase chain reaction (qPCR) and an immunochromatographic assay to investigate the feasibility of this method in optimizing detection of these common pathogens of the female reproductive tract.

Results

Compared with the manual culture method, the Copan WASP microbiology automation system detected fewer bacterial types (P<0.001) and bacterial colonies (P<0.001) but had a higher detection rate of single colonies (P<0.001). There was no significant difference in the detection rates of common pathogens encountered in clinical obstetrics and gynecology, including group B Streptococcus (GBS) (P=0.575) and Candida (P=0.917), between the two methods. Specimens collected in the Copan-ESwab tubes could be used for screening of GBS and CT via fluorescence-based qPCR but not with immunochromatography. However, UU and NG were not detected in any sample with either method; thus, further validation is required to determine the feasibility of the Copan system for screening these pathogens.

Conclusion

The Copan WASP microbiology automation system could facilitate the optimization of diagnostic procedures for detecting common pathogens of the female reproductive system, thereby reducing associated costs.

Acceptability and efficacy of vaginal self-sampling for genital infection and bacterial vaginosis: A cross-sectional study

BACKGROUND & AIM

Screening for genital infection (GI) such as bacterial vaginosis (BV) and yeast infection, for sexually transmitted infection (STI), and for asymptomatic carriage of group B streptococcus (GBS) in pregnant women are common reason for medical appointments. The diagnosis and control of GIs, STIs, and GBS are major issues, for fertility and overall well-being of affected women. Conventional testing is performed using vaginal/cervical classical sampling (VCS); this procedure requires pelvic examination performed by health care professionals which raises concerns among women. Vaginal-self-sampling (VSS), as an alternative to VCS, might capture more women. The aim was first to show non-inferiority of VSS compared with VCS to screen for GIs, STIs, and GBS; second to determine the feasibility of VSS.

METHODS

VSS and VCS from 1027 women were collected by health care professionals and simultaneously carried out on each patient. GIs, STIs, and GBS were systematically screened in both paired VSS and VCS samples. Non-inferiority of VSS compared with VCS was assessed using z statistic for binomial proportions.

RESULTS

Prevalence of GIs were 39.7% using VSS and 38.1% using VCS (p = 0.0016). Prevalence of STIs was 8.5% (VSS) vs 8.1% (VCS) (p = 0.0087). Prevalence of GBS was 13.4% (VSS) and 11.5% (VCS) (p = 0.0001). Most participants (84%) recommended the use of VSS.

CONCLUSIONS

This study shows that VSS was not inferior to VCS for the detection of GIs, STIs, and GBS. This study provides evidence that VSS can be used as a universal specimen for detection of lower genital tract infections in women.

STUDY IDENTIFICATION NUMBER

ID-RCB 2014-A01250-4.

Finding the Gaps in Retesting for Chlamydia and Gonorrhea: Differences Across High-Volume Testing Departments in an Urban Health Care Setting

BACKGROUND

The Centers of Disease Control and Prevention guidelines recommend that all patients be retested 3 months after a positive chlamydia (CT) or gonorrhea (GC) result. However, retest rates are generally low, and only a quarter of patients return to clinic for retesting. This analysis explored retesting patterns in a high sexually transmitted infection (STI)/human immunodeficiency virus (HIV)-risk setting to illuminate gaps in adherence to guideline recommendations.

METHODS

Retrospective chart data from a large urban safety-net institution were analyzed descriptively. Patients who received a positive CT/GC test from January to February 2017 were followed up for at least 4 months to assess if retesting occurred within approximately 3 months.

RESULTS

Our sample of 207 patients was primarily non-Hispanic Black (92.8%), younger than 25 years (63.3%) and women (60.4%). Over half had been initially diagnosed with CT, one-third with GC, and one-tenth with both CT and GC. Eighty-nine (43.0%) patients were retested during the observed period; mean time between tests was 2.7 months. Retesting was most common in infectious diseases/HIV primary care (73.6%) and obstetrics/gynecology (44.9%). Patients who were first diagnosed in emergency medicine were significantly less likely to be retested. Retested patients included a large number of HIV-positive men (31 of 89 total) and pregnant women (23 of 54 women).

CONCLUSIONS

Forty-three percent of patients were retested within approximately 3 months of their initial positive CT/GC diagnosis, exceeding previously published rates. Nonetheless, in light of the growing STI epidemic, health care systems should prioritize retesting across high-volume testing specialties, rethink retesting models, and facilitate referrals to ensure that patients receive guideline-recommended, comprehensive STI care.

The Stigma of Sexually Transmitted Infections

Evidence-based guidelines have improved diagnosis and treatment of sexually transmitted infections (STI). Social stigma remains a barrier to STI testing and is associated with underutilization of prevention services. Alternatives for STI testing (eg, in-home testing) are convenient. However, some individuals decline follow-up treatment in fear of unintentional disclosure of their diagnosis. This article reviews STI treatment guidelines and examines the impact of stigma and ethical issues on testing, adherence, partner notification, and transmission rates. An understanding of STI-associated ethical issues and controversies is an important step toward eliminating stigma and reducing STI prevalence and morbidity.

Mycoplasma genitalium, Chlamydia trachomatis, and Neisseria gonorrhoeae Detected With Aptima Assays Performed on Self-Obtained Vaginal Swabs and Urine Collected at Home and in a Clinic

Self-obtained vaginal swabs, first-void urine and pooled specimens were collected at home and in a clinic. Percent prevalence and collection site concordance was 30.3 and 100 for Mycoplasma genitalium (74.4% azithromycin resistant) 15.1 and 96.7 for Chlamydia trachomatis and 6.6 and 100 for Neisseria gonorrhoeae (27% ciprofloxacin-resistant).

Acceptability and feasibility of recruiting women to collect a self-administered vaginal swab at a pharmacy clinic for sexually transmissible infection screening

Willingness to self-collect vaginal swabs at a pharmacy clinic is of interest as a venue to increase sexually transmissible infections (STIs) screening for chlamydia, gonorrhoea and trichomonas. Women self-collected vaginal swabs at the pharmacy, completed questionnaires and received STI results within 2 h. Women with STIs were offered free treatment. A total of 313 of 777 (40.3%) women consented and prevalence for any STI was 3.9%. Questionnaires demonstrated acceptability for self-collection at the pharmacy, with 63% (95% CI 57.3-68) and 32.3% (95% CI 27.4-37.8) indicating they 'strongly agreed' or 'agreed' that they felt comfortable with pharmacy collection, respectively. Self-collected vaginal swabs for STI testing for women who were at a pharmacy were feasible and acceptable to women.

Accuracy of Curable Sexually Transmitted Infections and Genital Mycoplasmas Screening by Multiplex Real-Time PCR Using a Self-Collected Veil among Adult Women in Sub-Saharan Africa

Background

Sexually transmitted infections (STIs) are highly prevalent in sub-Saharan Africa. Genital self-sampling may facilitate the screening of STIs in hard-to-reach remote populations far from large health care centers and may increase screening rates. The cross-sectional GYNAUTO-STI study was carried out to assess the performance of a novel genital veil (V-Veil-Up Gyn Collection Device, V-Veil-Up Pharma, Ltd., Nicosia, Cyprus) as a genital self-sampling device to collect genital secretions to diagnose STIs by molecular biology as compared to reference clinician-collected genital specimens, in adult African women.

Methods

Adult women living in N'Djamena, the capital city of Chad, were recruited from the community and referred to the clinic for women's sexual health "La Renaissance Plus". A clinician obtained an endocervical specimen using flocked swab. Genital secretions were also obtained by self-collection using veil. Both clinician- and self-collected specimens were tested for common curable STIs (including Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis) and genital Mycoplasma spp. by multiplex real-time PCR (Allplex™ STI Essential Assay, Seegene, Seoul, South Korea). Test positivities for both collection methods were compared by assessing methods agreement, sensitivity, and specificity.

Results

A total of 251 women (mean age, 35.1 years) were prospectively enrolled. Only seven (2.8%) women were found to be infected with at least one common STIs [C. trachomatis: 3 (1.2%), N. gonorrhoeae: 1 (0.4%), M. genitalium: 4 (1.6%) and T. vaginalis: 1 (0.4%)], while the prevalence of genital mycoplasmas was much higher (54.2%) with a predominance of Ureaplasma parvum (42.6%). Self-collection by veil was non-inferior to clinician-based collection for genital microorganisms DNA molecular testing, with "almost perfect" agreement between both methods, high sensitivity (97.0%; 95%CI: 92.5-99.2%), and specificity (88.0%; 95%CI: 80.7-93.3%). Remarkably, the mean total number of genital microorganisms detected per woman was 1.14-fold higher in self-collected specimens compared to that in clinician-collected specimens.

Conclusions

Veil-based self-collection of female genital secretions constitutes a convenient tool to collect in gentle way cervicovaginal secretions for accurate molecular detection of genital bacteria. Such sampling procedure could be easily implemented in STIs clinics in sub-Saharan Africa.

Self-collection of samples as an additional approach to deliver testing services for sexually transmitted infections: a systematic review and meta-analysis

BACKGROUND

Self-collection of samples for diagnostic testing offers the advantages of patient autonomy, confidentiality and convenience. Despite data showing their feasibility and accuracy, there is a need to better understand how to implement such interventions for sexually transmitted infections (STIs). To support WHO guidelines on self-care interventions, we conducted a systematic review to investigate whether self-collection of samples should be made available as an additional approach to deliver STI testing services.

METHODS

Peer-reviewed studies were included if they compared individuals who self-collected samples for chlamydia, gonorrhoea, syphilis and/or trichomonas testing to individuals who had samples collected by clinicians on the following outcomes: uptake/frequency of STI testing, social harms/adverse events, positive yield (case finding), linkage to clinical assessment/treatment and reported sexual risk behaviour. We searched PubMed, CINAHL, LILACS and EMBASE for articles published through July 2018. Risk of bias was assessed using the Cochrane tool for randomised controlled trials (RCTs) and the Evidence Project tool for non-RCTs. Meta-analysis was conducted using random effects models to generate pooled estimates of relative risk (RR).

RESULTS

Eleven studies, including five RCTs and six observational studies with a total of 202 745 participants, met inclusion criteria. Studies were conducted in Australia, Denmark and the USA. Meta-analysis found that programmes offering self-collection of samples increased overall uptake of STI testing services (RR: 2.941, 95% CI 1.188 to 7.281) and case finding (RR: 2.166, 95% CI 1.043 to 4.498). No studies reported measuring STI testing frequency, social harms/adverse events, linkage to care or sexual risk behaviour.

DISCUSSION

While greater diversity in study designs, outcomes and settings would strengthen the evidence base, findings from this review suggest that self-collection of STI samples could be an effective additional strategy to increase STI testing uptake.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42018114866.

Home Self-Collection by Mail to Test for Human Papillomavirus and Sexually Transmitted Infections

OBJECTIVE

To evaluate the validity and acceptability of at-home self-collection to test for high-risk human papillomavirus (HPV) and sexually transmitted infections among women overdue for cervical cancer screening by national guidelines.

METHODS

Low-income, infrequently screened women were recruited from the general population in North Carolina to participate in an observational study. Participants provided two self-collected cervicovaginal samples (one at home and one in the clinic) and a clinician-collected cervical sample. Samples were tested for high-risk HPV, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium. Cervical samples were also tested by liquid-based cytology.

RESULTS

Overall, 193 women had conclusive high-risk HPV results for all three samples and cytology results. Prevalence of high-risk HPV within self-home samples (12.4%) was not different from that within clinician samples (11.4%; P=.79) and from that within self clinic samples (15.5%; P=.21). Positivity for high-risk HPV in all sample types increased with increasing grades of cervical abnormality (P<.001). Self-home samples detected high-risk HPV in all identified cases of high-grade squamous intraepithelial lesions and of cervical intraepithelial neoplasia 2 or worse. Detection was comparable across sample types for T vaginalis (range 10.2-10.8%), M genitalium (3.3-5.5%), C trachomatis (1.1-2.1%), and N gonorrhoeae (0-0.5%). Kappa values between sample types ranged from 0.56 to 0.66 for high-risk HPV, 0.86-0.91 for T vaginalis, and 0.65-0.83 for M genitalium. Most participants reported no difficulty understanding self-collection instructions (93.6%) and were willing to use self-collection in the future (96.3%).

CONCLUSION

Mail-based, at-home self-collection for high-risk HPV and sexually transmitted infection detection was valid and well accepted among infrequently screened women in our study. These findings support the future use of high-risk HPV self-collection to increase cervical cancer screening rates among higher risk women in the United States.

A service evaluation comparing home-based testing to clinic-based testing for Chlamydia and gonorrhoea in Birmingham and Solihull

Home-based testing is an alternative, convenient and cost-effective method of testing for sexually transmitted infections compared to traditional clinic-based testing, in patients who are asymptomatic and, or, would otherwise feel stigmatised about attending sexual health clinics. The sexual health service in Birmingham and Solihull, called Umbrella, provides an online home-based testing service, which has been in operation since August 2015. The aim of this study was to evaluate the uptake and return rate of home-based testing kits and compare home-based testing to clinic-based testing in terms of diagnosis and treatment rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). Our study showed that home-based testing is a popular method of testing and relatively more popular amongst asymptomatic, young, heterosexual female and White patients than clinic-based testing, with a return rate of 48%. The diagnosis rates for CT/GC are comparable to patients who attend clinic for testing (8% vs. 10% in home-based and clinic-based groups, respectively, p < 0.001). The overall treatment rate was lower in the home-based compared to the clinic-based group (82% vs. 88%, p < 0.001). Umbrella will continue to provide this service within Birmingham and Solihull and aim to provide patients with alternative pathways for more convenient access to treatment.

Comparing mail-in self-collected specimens sent via United States Postal Service versus clinic-collected specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae in extra-genital sites

Objectives

To evaluate the concordance between clinic-collected extra-genital specimens and self-collected mailed-in extra-genital specimens among participants seeking sexually transmitted infection testing at a free clinic in Hollywood, CA.

Methods

A convenience sample of 210 men who have sex with men were enrolled between February 29, 2016 and December 21, 2016 and received mail-in testing kits for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). All testing was performed using the GeneXpert® CT/NG (Cepheid, Sunnyvale, CA).

Results

From the 210 mail-in kits distributed, 149 mail-in kits (71.0%) were returned to the laboratory, resulting in 145 pairs (clinic-collected and mail-in) of rectal test results and 148 pairs of pharyngeal test results for both CT and NG detection. The concordance was 95.0% for all CT rectal tests, 99.3% for all CT pharyngeal tests, 95.7% for all NG rectal tests, and 97.2% for all NG pharyngeal tests.

Conclusion

Roughly two-thirds of mail-in test kits were returned and concordance was generally high, however more than one-third of positive results were missed in mail-in samples. The prevalence of potential false-negative results among mail-in samples warrants caution when implementing mail-in STI testing strategies.

Young Low-Risk Heterosexual Clients Prefer a Chlamydia Home Collection Test to a Sexually Transmitted Infection Clinic Visit in Amsterdam, the Netherlands, A Cross-Sectional Study

BACKGROUND

Home-based self-collection of specimens for urogenital and anorectal chlamydia testing has been proven feasible and acceptable. We studied the efficiency of chlamydia home collection kits for young low-risk persons to optimize care at the Amsterdam sexually transmitted infection (STI) clinic.

METHODS

Low-risk heterosexual persons under 25 years submitting an appointment request online were offered 3 different ways of chlamydia testing: (1) receiving a home collection kit, (2) coming to the clinic without, or (3) with sexual health counseling. The collection kit was sent to the client by surface mail and was used to self-collect a vaginal swab or urine sample (men). This sample was sent back to the laboratory for testing and the results could be retrieved online. Testing for gonorrhea, syphilis, and human immunodeficiency virus was indicated after testing chlamydia-positive.

RESULTS

Between September 2012 until July 2013, from 1804 online requests, 1451 (80%) opted for the home collection kit, 321 (18%) preferred an appointment at the clinic without, and 32 (2%) with sexual health counseling. Of the requested home collection kits, 88% were returned. Chlamydia was diagnosed in 6.0% of the clients receiving a home collection kit, and none of the chlamydia-positive clients tested positive for other STI.

CONCLUSIONS

Home collection is the preferred method for most young low-risk heterosexual clients who seek STI care. With a high compliance to collect and return the samples, home collection can be used as a tool to increase efficiency and dedicate STI clinic workers efforts to those at highest risk.

The acceptability and cost of a home-based chlamydia retesting strategy: findings from the REACT randomised controlled trial

BACKGROUND

Chlamydia retesting three months after treatment is recommended to detect reinfections, but retesting rates are typically low. The REACT (retest after Chlamydia trachomatis) randomised trial demonstrated that home-based retesting using postal home-collection kits and SMS reminders, resulted in substantial improvements in retesting rates in women, heterosexual men and men who have sex with men (MSM), with detection of more repeat positive tests compared with SMS reminder alone. In the context of this trial, the acceptability of the home-based strategy was evaluated and the costs of the two strategies were compared.

METHODS

REACT participants (200 women, 200 heterosexual men, 200 MSM) were asked to complete an online survey that included home-testing acceptability and preferred methods of retesting. The demographics, sexual behaviour and acceptability of home collection were compared between those preferring home-testing versus clinic-based retesting or no preference, using a chi-square test. The costs to the health system of the clinic-based and home retesting strategies and the cost per infection for each were also compared.

RESULTS

Overall 445/600 (74 %) participants completed the survey; 236/445 from the home-testing arm, and 141 of these (60 %) retested at home. The majority of home arm retesters were comfortable having the kit posted to their home (86 %); found it easy to follow the instructions and collect the specimens (96 %); were confident they had collected the specimens correctly (90 %); and reported no problems (70 %). Most (65 %) preferred home retesting, 21 % had no preference and 14 % preferred clinic retesting. Comparing those with a preference for home testing to those who didn't, there were significant differences in being comfortable having a kit sent to their home (p = 0.045); not having been diagnosed with chlamydia previously (p = 0.030); and living with friends (p = 0.034). The overall cost for the home retest pathway was $154 (AUD), compared to $169 for the clinic-based retesting pathway and the cost per repeat infection detected was $1409 vs $3133.

CONCLUSIONS

Among individuals initially diagnosed with chlamydia in a sexual health clinic setting, home-based retesting was shown to be highly acceptable, preferred by most participants, and cost-efficient. However some clients preferred clinic-based testing, often due to confidentiality concerns in their home environment. Both options should be provided to maximise retesting rates.

TRIAL REGISTRATION

The trial was registered with the Australia New Zealand Clinical Trials Registry on September 9, 2011: ACTRN12611000968976.

Background review for the '2015 European guideline on the management of Chlamydia trachomatis infections'

SummaryChlamydia trachomatis infections are major public health concerns globally. Of particular grave concern is that the majority of persons with anogenital Chlamydia trachomatis infections are asymptomatic and accordingly not aware of their infection, and this silent infection can subsequently result in severe reproductive tract complications and sequelae. The current review paper provides all background, evidence base and discussions for the 2015 European guideline on the management of Chlamydia trachomatis infections (Lanjouw E, et al. Int J STD AIDS 2015). Comprehensive information and recommendations are included regarding the diagnosis, treatment and prevention of anogenital, pharyngeal and conjunctival Chlamydia trachomatis infections in European countries. However, Chlamydia trachomatis also causes the eye infection trachoma, which is not a sexually transmitted infection. The 2015 European Chlamydia trachomatis guideline provides up-to-date guidance regarding broader indications for testing and treatment of Chlamydia trachomatis infections; clearer recommendation of using validated nucleic acid amplification tests only for diagnosis; advice on (repeated) Chlamydia trachomatis testing; recommendation of increased testing to reduce the incidence of pelvic inflammatory disease and prevent exposure to infection and recommendations to identify, verify and report Chlamydia trachomatis variants. Improvement of access to testing, test performance, diagnostics, antimicrobial treatment and follow-up of Chlamydia trachomatis patients are crucial to control its spread.

2015 European guideline on the management of Chlamydia trachomatis infections

Chlamydia trachomatis infections, which most frequently are asymptomatic, are major public health concerns globally. The 2015 European C. trachomatis guideline provides: up-to-date guidance regarding broader indications for testing and treatment of C. trachomatis infections; a clearer recommendation of using exclusively-validated nucleic acid amplification tests for diagnosis; advice on (repeated) C. trachomatis testing; the recommendation of increased testing to reduce the incidence of pelvic inflammatory disease and prevent exposure to infection; and recommendations to identify, verify and report C. trachomatis variants. Improvement of access to testing, test performance, diagnostics, antimicrobial treatment and follow-up of C. trachomatis patients are crucial to control its spread. For detailed background, evidence base and discussions, see the background review for the present 2015 European guideline on the management of Chlamydia trachomatis infections (Lanjouw E, et al. Int J STD AIDS. 2015).

Home-based versus clinic-based specimen collection in the management of Chlamydia trachomatis and Neisseria gonorrhoeae infections

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the most frequent causes of bacterial sexually transmitted infections (STIs). Management strategies that reduce losses in the clinical pathway from infection to cure might improve STI control and reduce complications resulting from lack of, or inadequate, treatment.

OBJECTIVES

To assess the effectiveness and safety of home-based specimen collection as part of the management strategy for Chlamydia trachomatis and Neisseria gonorrhoeae infections compared with clinic-based specimen collection in sexually-active people.

SEARCH METHODS

We searched the Cochrane Sexually Transmitted Infections Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS on 27 May 2015, together with the World Health Organization International Clinical Trials Registry (ICTRP) and ClinicalTrials.gov. We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of home-based compared with clinic-based specimen collection in the management of C. trachomatis and N. gonorrhoeae infections.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We contacted study authors for additional information. We resolved any disagreements through consensus. We used standard methodological procedures recommended by Cochrane. The primary outcome was index case management, defined as the number of participants tested, diagnosed and treated, if test positive.

MAIN RESULTS

Ten trials involving 10,479 participants were included. There was inconclusive evidence of an effect on the proportion of participants with index case management (defined as individuals tested, diagnosed and treated for CT or NG, or both) in the group with home-based (45/778, 5.8%) compared with clinic-based (51/788, 6.5%) specimen collection (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.60 to 1.29; 3 trials, I² = 0%, 1566 participants, moderate quality). Harms of home-based specimen collection were not evaluated in any trial. All 10 trials compared the proportions of individuals tested. The results for the proportion of participants completing testing had high heterogeneity (I² = 100%) and were not pooled. We could not combine data from individual studies looking at the number of participants tested because the proportions varied widely across the studies, ranging from 30% to 96% in home group and 6% to 97% in clinic group (low-quality evidence). The number of participants with positive test was lower in the home-based specimen collection group (240/2074, 11.6%) compared with the clinic-based group (179/967, 18.5%) (RR 0.72, 95% CI 0.61 to 0.86; 9 trials, I² = 0%, 3041 participants, moderate quality).

AUTHORS' CONCLUSIONS

Home-based specimen collection could result in similar levels of index case management for CT or NG infection when compared with clinic-based specimen collection. Increases in the proportion of individuals tested as a result of home-based, compared with clinic-based, specimen collection are offset by a lower proportion of positive results. The harms of home-based specimen collection compared with clinic-based specimen collection have not been evaluated. Future RCTs to assess the effectiveness of home-based specimen collection should be designed to measure biological outcomes of STI case management, such as proportion of participants with negative tests for the relevant STI at follow-up.

Screening for Asymptomatic Extragenital Gonorrhea and Chlamydia in Men Who Have Sex with Men: Significance, Recommendations, and Options for Overcoming Barriers to Testing

Men who have sex with men (MSM) have a disproportionately greater risk than other populations of acquiring Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), the two most commonly reported notifiable diseases in the United States according to the Centers for Disease Control and Prevention (CDC). The presence of either of these diseases is a significant risk factor for the acquisition and transmission of human immunodeficiency virus (HIV). Recent studies have shown that significant rates of asymptomatic GC and CT infection are found at the extragenital oropharygeal and rectal sites in MSM, with or without concurrent urogenital infection. However, extragenital sites are not being routinely screened and, thus, many asymptomatic GC and CT infections at the oropharyngeal and rectal sites may go undiagnosed. This review will begin with the current evidence-based screening recommendations for extragenital GC and CT in MSM. This will be followed by recently reported extragenital GC and CT infection rates in asymptomatic MSM, and a discussion of the risks and potential implications of undiagnosed extragenital GC and CT infections. Finally, a discussion on the frequency of, and potential barriers to, screening will be presented with a summary of potential interventions for increasing screening frequency found in the literature. The scope of this review will focus primarily on U.S. recommendations, infection rates, and screening frequencies, with the inclusion of relevant international recommendations and studies for comparative and illustrative purposes.

A mixed methods approach to assess the likelihood of testing for STI using self-collected samples among behaviourally bisexual women

OBJECTIVES

Behaviourally bisexual women (women who have sex with women and men (WSWM)) are more likely to report a history of sexually transmitted infections (STI) than women who have sex exclusively with men or exclusively with women. Barriers to care may prohibit WSWM from seeking STI testing. The present study investigated participant willingness to self-collect oral, vaginal and anal samples for STI testing.

METHODS

Eighty WSWM were recruited from two midwestern locations. After completing an online questionnaire, a subset of the participants were interviewed (n=54) and provided the option to self-collect oral, vaginal and/or anal samples to screen for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis.

RESULTS

Over two-thirds (67.5%, n=54) of the participants completed the baseline scheduled and attended the interview. The majority of these participants provided vaginal (87.0%, n=47), oral (85.2%, n=46) and/or anal (61.1%, n=33) samples. Participants with a history of anal play were significantly more likely to provide an anal sample. C. trachomatis infection was identified in the samples of 6.8% (n=3) of the participants including 4.5% (n=2) of the vaginal samples and 3.3% (n=1) of the anal samples. None of the samples were positive for N. gonorrhoeae or T. vaginalis. Participants who reported a recent history of anal sexual behaviour with a male partner were significantly more likely to self-collect an anal sample.

CONCLUSIONS

Given the comparatively high STI rates among WSWM, self-sampling in non-traditional settings may present a unique opportunity to provide needed care to this underserved population of women.

Rationale and design of REACT: a randomised controlled trial assessing the effectiveness of home-collection to increase chlamydia retesting and detect repeat positive tests

BACKGROUND

Repeat infection with Chlamydia trachomatis is common and increases the risk of sequelae in women and HIV seroconversion in men who have sex with men (MSM). Despite guidelines recommending chlamydia retesting three months after treatment, retesting rates are low. We are conducting the first randomised controlled trial to assess the effectiveness of home collection combined with short message service (SMS) reminders on chlamydia retesting and reinfection rates in three risk groups.

METHODS/DESIGN

The REACT (retest after Chlamydia trachomatis) trial involves 600 patients diagnosed with chlamydia: 200 MSM, 200 women and 200 heterosexual men recruited from two Australian sexual health clinics where SMS reminders for retesting are routine practice. Participants will be randomised to the home group (3-month SMS reminder and home-collection) or the clinic group (3-month SMS reminder to return to the clinic). Participants in the home group will be given the choice of attending the clinic if they prefer. The mailed home-collection kit includes a self-collected vaginal swab (women), UriSWAB (Copan) for urine collection (heterosexual men), and UriSWAB plus rectal swab (MSM). The primary outcome is the retest rate at 1-4 months after a chlamydia diagnosis, and the secondary outcomes are: the repeat positive test rate; the reinfection rate; the acceptability of home testing with SMS reminders; and the cost effectiveness of home testing. Sexual behaviour data collected via an online survey at 4-5 months, and genotyping of repeat infections, will be used to discriminate reinfections from treatment failures. The trial will be conducted over two years. An intention to treat analysis will be conducted.

DISCUSSION

This study will provide evidence about the effectiveness of home-collection combined with SMS reminders on chlamydia retesting, repeat infection and reinfection rates in three risk groups. The trial will determine client acceptability and cost effectiveness of this strategy.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12611000968976.

Discordant prevalence of Chlamydia trachomatis in asymptomatic couples screened by two screening approaches

This study was carried out to observe the effect of screening both members of an asymptomatic couple for Chlamydia trachomatis. First void urine samples were collected from 105 women and their male sex partners. Women were recruited for screening at a sexual health clinical setting (age 16–25 years), and home sampling screening options were used for men. Using PCR we detected seven positive C. trachomatis samples in women (6.6%) and five in men (4.6%). The concordant infection rate was 33% (3/9 couples). Routine urine screening of the female partner might result in substantial underestimation of the C. trachomatis prevalence within the couple, where perhaps 56% of the couples where at least one partner tested positive would remain undiagnosed. Screening both partners compared with women- or men-only screening increased the detection rate of positive couples. Furthermore, the use of alternative screening approaches in different clinical settings increases testing in at risk populations.

Advances and challenges in biosensor-based diagnosis of infectious diseases

Rapid diagnosis of infectious diseases and timely initiation of appropriate treatment are critical determinants that promote optimal clinical outcomes and general public health. Conventional in vitro diagnostics for infectious diseases are time-consuming and require centralized laboratories, experienced personnel and bulky equipment. Recent advances in biosensor technologies have potential to deliver point-of-care diagnostics that match or surpass conventional standards in regards to time, accuracy and cost. Broadly classified as either label-free or labeled, modern biosensors exploit micro- and nanofabrication technologies and diverse sensing strategies including optical, electrical and mechanical transducers. Despite clinical need, translation of biosensors from research laboratories to clinical applications has remained limited to a few notable examples, such as the glucose sensor. Challenges to be overcome include sample preparation, matrix effects and system integration. We review the advances of biosensors for infectious disease diagnostics and discuss the critical challenges that need to be overcome in order to implement integrated diagnostic biosensors in real world settings.

Comparative effectiveness and acceptability of home-based and clinic-based sampling methods for sexually transmissible infections screening in females aged 14-50 years: a systematic review and meta-analysis

BACKGROUND

Home-based sampling is a strategy to enhance uptake of sexually transmissible infection (STI) screening. This review aimed to compare the screening uptake levels of home-based self-sampling and clinic-based specimen collection for STIs (chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and trichomoniasis) in females aged 14-50 years. Acceptability and effect on specimen quality were determined.

METHODS

Sixteen electronic databases were searched from inception to September 2012. Randomised controlled trials (RCTs) comparing the uptake levels of home-based self-sampling and clinic-based sampling for chlamydia, gonorrhoea and trichomoniasis in females aged 14-50 years were eligible for inclusion. The risk of bias in the trials was assessed. Risk ratios (RRs) for dichotomous outcomes were meta-analysed.

RESULTS

Of 3065 papers, six studies with seven RCTs contributed to the final review. Compared with clinic-based methods, home-based screening increased uptake significantly (P=0.001-0.05) in five trials and was substantiated in a meta-analysis (RR: 1.55; 95% confidence interval: 1.30-1.85; P=0.00001) of two trials. In three trials, a significant preference for home-based testing (P=0.001-0.05) was expressed. No significant difference was observed in specimen quality. Sampling was rated as easy by a significantly higher number of women (P=0.01) in the clinic group in one trial.

CONCLUSIONS

The review provides evidence that home-based testing results in greater uptake of STI screening in females (14-50 years) than clinic-based testing without compromising quality in the developed world. Home collection strategies should be added to clinic-based screening programs to enhance uptake.

Sexually transmitted infection testing practices among 'money boys' and general men who have sex with men in Shanghai, China: objective versus self-reported status

Little is known about sexually transmitted infection (STI) testing among Chinese men who have sex with men (MSM). This study describes the prevalence of STI testing, associated factors and the validity of STI self-reporting among Chinese MSM. Findings indicated a high prevalence of STIs and low testing rates among MSM in Shanghai. Monthly income was significantly associated with STI testing (odds ratio: 0.37, 95% confidence interval (CI): 0.18 to 0.76). Depression was significantly associated with STI testing for general MSM (odds ratio: 1.09, 95% CI: 1.01 to 1.17). Syphilis self-reported status had the highest validity (k=0.33, χ(2)=3.76, 95% CI: -0.003 to 0.65). Efforts are needed to ensure that STI testing services are accessible to MSM in China. Future HIV and STI interventions should be tailored to the needs of different subsets of MSM.

Control of Neisseria gonorrhoeae in the era of evolving antimicrobial resistance

Neisseria gonorrhoeae has developed resistance to all previous first-line antimicrobial therapies over the past 75 years. Today the cephalosporins, the last available antibiotic class that is sufficiently effective, are also threatened by evolving resistance. Screening for asymptomatic gonorrhea in women and men who have sex with men, treating with a dual antibiotic regimen, ensuring effective partner therapy, and remaining vigilant for treatment failures constitute critical activities for clinicians in responding to evolving antimicrobial resistance. This article reviews the epidemiology, history of antimicrobial resistance, current screening and treatment guidelines, and future treatment options for gonorrhea.

Home-based chlamydia and gonorrhoea screening: a systematic review of strategies and outcomes

Background

In many countries, low Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) screening rates among young people in primary-care have encouraged screening programs outside of clinics. Nucleic acid amplification tests (NAATs) make it possible to screen people in homes with self-collected specimens. We systematically reviewed the strategies and outcomes of home-based CT/NG screening programs.

Methods

Electronic databases were searched for home-based CT and/or NG screening studies published since January 2005. Screening information (e.g. target group, recruitment and specimen-collection method) and quantitative outcomes (e.g. number of participants, tests and positivity) were extracted. The screening programs were classified into seven groups on the basis of strategies used.

Results

We found 29 eligible papers describing 32 home-based screening programs. In seven outreach programs, people were approached in their homes: a median of 97% participants provided specimens and 76% were tested overall (13717 tests). In seven programs, people were invited to receive postal test-kits (PTKs) at their homes: a median of 37% accepted PTKs, 79% returned specimens and 19% were tested (46225 tests). PTKs were sent along with invitation letters in five programs: a median of 33% returned specimens and 29% of those invited were tested (15126 tests). PTKs were requested through the internet or phone without invitations in four programs and a median of 32% returned specimens (2666 tests). Four programs involved study personnel directly inviting people to receive PTKs: a median of 46% accepted PTKs, 21% returned specimens and 9.1% were tested (341 tests). PTKs were picked-up from designated locations in three programs: a total of 6765 kits were picked-up and 1167 (17%) specimens were returned for screening. Two programs used a combination of above strategies (2395 tests) but the outcomes were not reported separately. The overall median CT positivity was 3.6% (inter-quartile range: 1.7-7.3%).

Conclusions

A variety of strategies have been used in home-based CT/NG screening programs. The screening strategies and their feasibility in the local context need to be carefully considered to maximize the effectiveness of home-based screening programs.

Systematic screening with information and home sampling for genital Chlamydia trachomatis infections in young men and women in Norway: a randomized controlled trial

BACKGROUND

As most genital Chlamydia trachomatis infections are asymptomatic, many patients do not seek health care for testing. Infections remain undiagnosed and untreated. We studied whether screening with information and home sampling resulted in more young people getting tested, diagnosed and treated for chlamydia in the three months following the intervention compared to the current strategy of testing in the health care system.

METHOD

We conducted a population based randomized controlled trial among all persons aged 18-25 years in one Norwegian county (41 519 persons). 10 000 persons (intervention) received an invitation by mail with chlamydia information and a mail-back urine sampling kit. 31 519 persons received no intervention and continued with usual care (control). All samples from both groups were analysed in the same laboratory. Information on treatment was obtained from the Norwegian Prescription Database (NorPD). We estimated risk ratios and risk differences of being tested, diagnosed and treated in the intervention group compared to the control group.

RESULTS

In the intervention group 16.5% got tested and in the control group 3.4%, risk ratio 4.9 (95% CI 4.5-5.2). The intervention led to 2.6 (95% CI 2.0-3.4) times as many individuals being diagnosed and 2.5 (95% CI 1.9-3.4) times as many individuals receiving treatment for chlamydia compared to no intervention in the three months following the intervention.

CONCLUSION

In Norway, systematic screening with information and home sampling results in more young people being tested, diagnosed and treated for chlamydia in the three months following the intervention than the current strategy of testing in the health care system. However, the study has not established that the intervention will reduce the chlamydia prevalence or the risk of complications from chlamydia.

Female genital Chlamydia trachomatis infection: where are we heading?

INTRODUCTION

Urogenital infection by Chlamydia trachomatis is the most common bacterial sexually transmitted disease in the world. C. trachomatis is the etiologic agent of several common genital tract syndromes such as urethritis, cervicitis, and pelvic inflammatory disease in women.

MATERIALS AND METHODS

In this review, the pathophysiology of a chlamydial infection as well as diagnosis, therapy and prevention strategies regarding female chlamydial infection are reviewed.

RESULTS

A chlamydial infection results in minimal or even no symptoms in approximately two-thirds of women, remaining therefore clinically apparent and undiagnosed. C. trachomatis infections are of great socioeconomic and public health concern due to the potential for severe long-term consequences in women, including an increased risk of ectopic pregnancy, tubal infertility and chronic pelvic pain. Moreover, if the bacterium is transmitted during labor to a newborn, it can cause ophthalmia neonatorum and atypical neonatal pneumonia. Due to the documented increased risk of morbidity, several national guidelines are available, including a routine screening for young women and screening during pregnancy that is recommended in several countries.

DISCUSSION

A routine screening for young women and screening during pregnancy is recommended in several countries. However, additional prospective studies of the effectiveness of chlamydia screening are warranted and might be feasible within established screening programs. Moreover, the transition from cervicitis to infertility should be also evaluated in future controlled studies to underline the existing evidence. Additionally, there is an urgent need to educate and inform health-care providers about implementation of screening programs to reduce the spread of chlamydial infection. Moreover, awareness and use of screening programs by the public is needed, which requires informational campaigns for the general public using different media. For improved screening strategies and public awareness, novel approaches have to be developed and evaluated. Finally, guidelines should be actively disseminated to all medical practitioners to increase their use in daily practice. Although the major socioeconomic and public health concerns of C. trachomatis infection are recognized, several considerations and additional measures for addressing this increasingly urgent health problem remain.