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.

Chlamydia screening for pregnant women aged 16-25 years attending an antenatal service: a cost-effectiveness study.

OBJECTIVE: Determine the cost-effectiveness of screening all pregnant women aged 16-25 years for chlamydia compared with selective screening or no screening. DESIGN: Cost effectiveness based on a decision model. SETTING: Antenatal clinics in Australia. SAMPLE: Pregnant women, aged 16-25 years. METHODS: Using clinical data from a previous study, and outcomes data from the literature, we modelled the short-term perinatal (12-month time horizon) incremental direct costs and outcomes from a government (as the primary third-party funder) perspective for chlamydia screening. Costs were derived from the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme, and average cost-weights reported for hospitalisations classified according to the Australian refined diagnosis-related groups. MAIN OUTCOME MEASURES: Direct costs of screening and managing chlamydia complications, number of chlamydia cases detected and treated, and the incremental cost-effectiveness ratios were estimated and subjected to sensitivity analyses. RESULTS: Assuming a chlamydia prevalence rate of 3%, screening all antenatal women aged 16-25 years at their first antenatal visit compared with no screening was $34,931 per quality-adjusted life-years gained. Screening all women could result in cost savings when chlamydia prevalence was higher than 11%. The incremental cost-effectiveness ratios were most sensitive to the assumed prevalence of chlamydia, the probability of pelvic inflammatory disease, the utility weight of a positive chlamydia test and the cost of the chlamydia test and doctor's appointment. CONCLUSION: From an Australian government perspective, chlamydia screening of all women aged 16-25 years old during one antenatal visit was likely to be cost-effective compared with no screening or selective screening, especially with increasing chlamydia prevalence. TWEETABLE ABSTRACT: Chlamydia screening for all pregnant women aged 16-25 years during an antenatal visit is cost effective.

Routine CD4 cell count monitoring seldom contributes to clinical decision-making on antiretroviral therapy in virologically suppressed HIV-infected patients.

OBJECTIVES: In Australia, CD4 cell count is monitored approximately every 6 months in HIV-infected patients during antiretroviral therapy (ART). The aim of this study was to determine if routine CD4 monitoring contributed to decisions on changes to ART, and to estimate how reduced CD4 monitoring could contribute to cost savings in Australia. METHODS: We conducted a retrospective cohort analysis investigating all HIV-infected patients who attended the Melbourne Sexual Health Centre (MSHC) in Australia from 1 April 2011 to 1 October 2013. We reviewed the electronic medical records of all patients who changed or stopped antiretroviral regimens during this time period to determine whether CD4 cell count could have contributed to this clinical decision. RESULTS: Among 1004 patients with HIV infection on ART, none [95% confidence interval (CI) 0-2.3%] of the 162 clinical decisions to change or stop treatment were influenced by CD4 cell counts. Reducing the current biannual CD4 monitoring strategy to annually could potentially save ∼AU$ 1.5 million (US$ 1.4 million) each year in Australia [i.e. ∼AU$ 74 700 (US$ 67 700) could be saved per 1000 HIV-infected patients during ART]. CONCLUSIONS: Routine CD4 monitoring in HIV-infected patients during ART could be reduced from biannually to annually, as it rarely influences clinical decisions in patients' management. Not only could this avoid patients being unnecessarily anxious about normal fluctuations in their CD4 counts but it would also result in cost savings.

Acceptability of digital anal cancer screening examinations in HIV-positive homosexual men.

OBJECTIVES: Anal cancer is more common in HIV-positive homosexual men than in HIV-negative homosexual men and the general population. Earlier diagnosis leads to improved prognosis. We aimed to determine if regular anal inspection and digital examination of asymptomatic homosexual men attending for routine HIV care were acceptable and to record the rate of referral for diagnosis of potentially malignant anal lesions. METHODS: We offered anal examinations to consecutive homosexual men with HIV infection aged ≥ 35 years during their routine HIV clinic visits, aiming to complete three examinations over a 12-month period. Acceptability questionnaires were completed at baseline and after each examination and doctors recorded examination findings and all resulting interventions. Hospital referral outcomes were collected and interventions were costed using the Australian Medical Benefits Schedule. RESULTS: Of 142 men who were offered enrolment in the study, 102 [72%; 95% confidence interval (CI) 64-79%] participated. Following the initial anal examinations, four men were referred to surgeons. Cancer was excluded in three men (3%; 95% CI 1-8%) and one was diagnosed with anal squamous cell carcinoma (SCC). Three men had anoscopy performed at the time and two were referred for colonoscopy. Ninety-eight per cent (95% CI 93-100%) of respondents said that they would probably have the examination next time. The intervention was estimated to cost approximately Australian $16 per examination. CONCLUSIONS: Regular anal digital examinations are an acceptable and inexpensive addition to the routine care of homosexual men with HIV infection.

Nonoccupational post-exposure prophylaxis source tracing: is it really feasible in Australia?

OBJECTIVE: A Swiss nonoccupational post-exposure prophylaxis (NPEP) source-tracing study successfully reduced unnecessary NPEP prescriptions by recruiting and testing source partners of unknown HIV serostatus. The Victorian NPEP Service in Australia attempted to replicate this study with the addition of HIV rapid testing and a mobile service. METHODS: Patients presenting to two busy NPEP sites who reported a source partner of unknown HIV status were routinely asked if their source could be traced. If the exposed person indicated that their source partner was traceable they were asked to contact them and discuss the possibility of having an HIV test. RESULTS: No sources were enrolled and the study was terminated. CONCLUSION: We hypothesize that there are a number of differences between Australia and Switzerland that make source tracing unfeasible in Australia.

Legislation requiring monthly testing of sex workers with low rates of sexually transmitted infections restricts access to services for higher-risk individuals.

OBJECTIVES: In Victoria, Australia, legislation requires sex workers to undergo monthly testing for gonorrhoea, chlamydia and trichomonas, and 3-monthly for HIV and syphilis, despite extremely low rates of sexually transmitted infections (STI) in female sex workers (FSW). The aim of this study was to quantify the resources and opportunities lost from this screening. METHODS: Computerised medical records of patients attending the Melbourne Sexual Health Centre (MSHC) between October 2005 and October 2008 were reviewed. RESULTS: Consultations with FSW accounted for 15.1% of total consultation time (5722 of 37,670 h) and of these, 2896 h (7.7%) were used for monthly consultations involving testing for gonorrhoea, chlamydia and trichomonas, but no serology (termed swab-only testing). Only 133 (3.2%) of the 4208 cases of STI (defined as gonorrhoea, chlamydia, trichomonas, early syphilis, mycoplasma genitalium or HIV) that were detected at MSHC during the study period were among FSW who underwent swab-only testing. 1726 (41%) STI were detected among men who have sex with men (MSM). The STI detected per 100 h of consultation time was (fourfold) higher for MSM (19) than for FSW (4). If FSW were tested only every 3 months for gonorrhoea, chlamydia, trichomonas, syphilis and HIV the 2896 h spent on monthly swab-only testing would have been available for higher-risk clients CONCLUSION: The current legislation requiring monthly STI testing is compromising the access for higher-risk individuals to sexual health. Other countries contemplating mandatory testing need to consider the influence that the frequency of testing has on access to sexual health services for high-risk groups.

The psychosocial burden of human papillomavirus related disease and screening interventions.

OBJECTIVES: (i) To assess the psychosocial burden of testing for human papillomavirus (HPV) related genital disease or of a HPV-related diagnosis; (ii) to compare an instrument specifically designed to measure HPV-related psychosocial burden with other generic quality of life (QoL) instruments. METHODS: A cross-sectional design. Researchers recruited women from outpatient clinics at a major tertiary women's hospital and a sexual health centre who completed surveys within 3 months of receiving RESULTS: 331 women, 18-45 years, who had experienced a normal cervical Papanicolaou (Pap) result, an abnormal Pap result, biopsy confirmed cervical intraepithelial neoplasia (CIN) or external genital warts (EGW). MAIN OUTCOME MEASURES: The HPV impact profile (HIP) designed to assess the psychosocial impact of HPV; two general health-related QoL surveys-the EuroQoL VAS and the Sheehan disability scale; and a HPV knowledge survey. RESULTS: Response rate was 78%. Significant psychosocial impacts were found for women screened for, or having a diagnosis of, HPV-related genital disease. The largest impact was in women with CIN 2/3 and EGW. This HPV-related psychosocial impact was most sensitively detected with the HIP. Relative to generic measures of QoL, the HIP provided insight into the full range of psychosocial impacts of HPV testing and diagnoses. CONCLUSIONS: Clinicians need to be aware of the potential psychosocial impact of testing for or diagnosing HPV-related genital disease, in particular CIN 2/3 and EGW. The HIP survey is a more sensitive measure of the psychosocial impact of HPV-related genital disease than generic QoL surveys.

What female patients feel about the offer of a chaperone by a male sexual health practitioner.

The aim of this study was to determine the experience and views of female patients when they were offered a chaperone by a male sexual health practitioner for a genital examination. Between November 2007 and January 2008, an anonymous survey was administered to female patients seen by male practitioners at Melbourne Sexual Health Centre. None of the 79 (95% CI 0-5%) patients who were offered a chaperone and declined one reported that they were uncomfortable declining the offer. The qualitative analysis showed that some participants appreciated being offered the option of a chaperone even if they did not want one and that the professional attributes of the practitioner influenced their decision not to have a chaperone. Only 8% (95%CI 4-15%) felt uncomfortable when asked if they would like a chaperone. The results reassure that when a female patient declines the offer of a chaperone within a sexual health clinic, the male practitioner can feel confident that this is the expression of the patient's wish.

Risk profile of walk-in triage compared with an appointment-based phone-triage evening clinic.

The aim of this study is to compare risk factors in new clients attending the walk-in triage-based day clinic (WITS) to those attending a telephone-triage appointment-based evening clinic of a sexual health service. The method involves an audit of computerized medical records of new clients attending between July 2002 and December 2007. There were 37,833 new clients of which 37,223 (98.4%) attended WITS and 610 (1.6%) attended the evening clinic. WITS clients were significantly older (31% vs. 30%, P < 0.041), more likely to be male (58% vs. 43%, P < 0.001), sex workers (6% vs. 3%, P < 0.001), not employed (34% vs. 10%, P < 0.001), diagnosed with gonorrhoea (1.7% vs. 0.7%, P < 0.041), herpes (4% vs. 2%, P < 0.000), non-specific urethritis (6% vs. 2%, P < 0.000) and less likely asymptomatic (35.1% vs. 53.4%, P < 0.001). Men attending WITS had significantly more female partners in the 12 months (3.9 vs. 3.0, P < 0.001), but other risks were similar in both clinics. A telephone-triage appointment-based evening clinic is important for asymptomatic high-risk individuals.

Chlamydia testing and notification in Australia: more money, more tests.

BACKGROUND: To examine the associations between chlamydia testing and notification and age, sex, socioeconomic status and access to services for area of residence for the Australian state of Victoria in 2004. METHODS: Data on 71 295 tests and 7006 notifications for chlamydia were obtained by age, gender and area of residence. Each area of residence was assigned to a population-weighted quartile of socioeconomic advantage and was scored for access to services. Generalised linear modelling was used to analyse relationships between the variables. RESULTS: The odds of being tested for and notified with chlamydia increased by 27% (odds ratio (OR) 1.27, 95% CI 1.26 to 1.27) and 10% (OR 1.10, 95% CI 1.08 to 1.13), respectively, and the odds of a test being positive decreased by 13% (OR 0.87, CI 0.85 to 0.89) for each quartile increase in socioeconomic advantage, when adjusted for access to services. The highest proportion of any subgroup population tested was 7.8% in women aged 20-24 years living in the most advantaged quartile. Men and women over 25 years in advantaged areas receive more testing than men and women aged 20-24 years in disadvantaged areas. CONCLUSION: Access to chlamydia testing is inequitable and favours more advantaged areas. Testing in the age groups at most risk, women aged between 20 and 24 years, was low even in those living in the most advantaged quartile. If Australia is to implement a chlamydia screening programme, education should emphasise the appropriate age group to screen.

Differences in length of stay for Hospital in the Home patients: comparing simple clinical coding with medical record review.

AIM: To determine whether the apparently longer length of stay (LOS) reported for patients with cellulitis managed in Hospital in the Home (HITH) compared with those managed as inpatients was correct. METHODS: Data, including LOS, from the Victorian In-patient Minimum Database (VIMD) of all patients with cellulitis managed between July 1998 and June 1999 at a large metropolitan teaching hospital were analysed and compared with a retrospective medical record review of the same patients. RESULTS: In the VIMD data, there were 266 episodes of cellulitis during the study period. However, the medical record review found that six episodes were not separate, but rather a continuation of treatment for the same episode of cellulitis, and that 18 were not episodes of cellulitis, but were pilonidal sinus infections. In the VIMD data set, the mean LOS for patients treated in HITH was generally longer than that for inpatients (7.2 days vs 5.1 days, respectively, P = 0.002). However, in the retrospective medical record review, the LOS for patients treated in HITH was similar to inpatients (7.3 days versus 7.0 days, respectively, P = 0.68). CONCLUSIONS: In contrast to the VIMD data, the medical record review demonstrated that, overall, patients with cellulitis had a similar LOS irrespective of whether they were managed at home or in hospital. This study confirms that caution is required in interpreting the VIMD data, highlights the importance of carefully monitoring the introduction of new treatment modalities and indicates areas for further research.

Patient-administered tampon-collected genital cells in the assessment of Chlamydia trachomatis infection using polymerase chain reaction.

BACKGROUND: Diagnosis of genital Chlamydia trachomatis infection in women traditionally requires a speculum examination to collect endocervical cells, followed by cell culture. This method is time consuming, requires stringent transport conditions, and is technically demanding. GOALS: To compare tampons as a patient-administered collection method followed by detection with polymerase chain reaction (PCR) with the traditional endocervical swab culture followed by cell culture detection. STUDY DESIGN: At the emergency department of a hospital for obstetrics and gynecology, 1,000 consecutive women with symptoms suggestive of infection with C. trachomatis were tested for C. trachomatis infection by PCR on both tampon (PCR-T) and swab (PCR-S) specimen and by culture of the swab specimen. RESULTS: Seventeen PCR-T and 16 PCR-S specimens were positive; 16 endocervical specimens were positive by culture, and 14 of the endocervical samples were positive by the three methods. Sixty-one PCR-S samples were inadequate as shown by the lack of amplification of the beta-globin gene segment, indicating poor collection of specimens by endocervical swab for chlamydial testing. CONCLUSIONS: Tampon specimens collected for PCR detection provided an easy and sensitive method of detection of C. trachomatis and overcame the obstacle of endocervical sampling and subsequent stringent transport requirements of culture.

Tampons: a novel patient-administered method for the assessment of genital human papillomavirus infection.

Assessment of human papillomavirus (HPV) infection usually requires a speculum examination to collect genital specimens. A technique using tampons as a patient-administered method for the collection of specimens was studied by dot blot hybridization (HPV types 6, 11, 16, 18, 31, and 33) and polymerase chain reaction (PCR). Tampons and cervical scrapes were collected from 48 consecutive women attending a dysplasia clinic. Tampons provided a significantly larger pellet volume (P less than .002) and more DNA (P less than .01) than scrapes. There was a close correlation when samples were analyzed for the presence of HPV DNA. Using dot blot hybridization, 8 cervical scrapes (17%) and 9 tampons (19%) were positive for HPV DNA (90% correlation). By PCR, 35 cervical scrapes (73%) and 33 tampons (69%) were positive for HPV DNA (88% correlation). Thus, tampon specimens are an easy method for assessment of genital HPV infection.