Kate Folkard

Screening for gonorrhoea using samples collected through the English National Chlamydia Screening Programme and risk of false positives: a national survey of Local Authorities

Objectives To investigate use of dual tests for Chlamydia trachomatis and Neisseria gonorrhoeae on samples collected through the National Chlamydia Screening Programme (NCSP) in England. Design and setting During May–July 2013, we delivered an online survey to commissioners of sexual health services in the 152 upper-tier English Local Authorities (LAs) who were responsible for commissioning chlamydia screening in people aged 15–24 years. Main outcome measures (1) The proportion of English LAs using dual tests on samples collected by the NCSP; (2) The estimated number of gonorrhoea tests and false positives from samples collected by the NCSP, calculated using national surveillance data on the number of chlamydia tests performed, assuming the gonorrhoea prevalence to range between 0.1% and 1%, and test sensitivity and specificity of 99.5%. Results 64% (98/152) of LAs responded to this national survey; over half (53% (52/98)) reported currently using dual tests in community settings. There was no significant difference between LAs using and not using dual tests by chlamydia positivity, chlamydia diagnosis rate or population screening coverage. Although positive gonorrhoea results were confirmed with supplementary tests in 93% (38/41) of LAs, this occurred after patients were notified about the initial positive result in 63% (26/41). Approximately 450–4500 confirmed gonorrhoea diagnoses and 2300 false-positive screens might occur through use of dual tests on NCSP samples each year. Under reasonable assumptions, the positive predictive value of the screening test is 17–67%. Conclusions Over half of English LAs already commission dual tests for samples collected by the NCSP. Gonorrhoea screening has been introduced alongside chlamydia screening in many low prevalence settings without a national evidence review or change of policy. We question the public health benefit here, and suggest that robust testing algorithms and clinical management pathways, together with rigorous evaluation, be implemented wherever dual tests are deployed.

Detection of Chlamydia trachomatis in rectal specimens in women and its association with anal intercourse: a systematic review and meta-analysis.

Objectives Chlamydia trachomatis is the most commonly diagnosed bacterial STI. Lack of prevalence and risk factor data for rectal chlamydia in women has testing and treatment implications, as azithromycin (a first-line urogenital chlamydia treatment) may be less effective for rectal chlamydia. We conducted a systematic review of studies on women in high-income countries to estimate rectal chlamydia prevalence, concurrency with urogenital chlamydia and associations with reported anal intercourse (AI). Design Systematic review and four meta-analyses conducted using random-effects modelling. Data sources Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and the Cochrane Database were searched for articles published between January 1997 and October 2017. Eligibility criteria Studies reporting rectal chlamydia positivity in heterosexual women aged ≥15 years old in high-income countries were included. Studies must have used nucleic acid amplification tests and reported both the total number of women tested for rectal chlamydia and the number of rectal chlamydia infections detected. Conference abstracts, case reports and studies with self-reported diagnoses were excluded. Data extracted included setting, rectal and urogenital chlamydia testing results, AI history, and demographics. Results Fourteen eligible studies were identified, all among diverse populations attending sexual health services. Among routine clinic-attending women, summary rectal chlamydia positivity was 6.0% (95% CI 3.2% to 8.9%); summary concurrent rectal chlamydia infection was 68.1% in those who tested positive for urogenital chlamydia (95% CI 56.6% to 79.6%); and of those who tested negative for urogenital chlamydia, 2.2% (95% CI 0% to 5.2%) were positive for rectal chlamydia. Reported AI was not associated with rectal chlamydia (summary risk ratio 0.90; 95% CI 0.75 to 1.10). Conclusions High levels of rectal chlamydia infection have been shown in women with urogenital chlamydia infection. The absence of association between reported AI and rectal chlamydia suggests AI is not an adequate indicator for rectal testing. Further work is needed to determine policy and practice for routine rectal testing in women.

Chlamydia and HIV testing, contraception advice, and free condoms offered in general practice: a qualitative interview study of young adults’ perceptions of this initiative

Background Opportunistic chlamydia screening is actively encouraged in English general practices. Based on recent policy changes, Public Health England piloted 3Cs and HIV in 2013–2014, integrating the offer of chlamydia testing with providing condoms, contraceptive information, and HIV testing (referred to as 3Cs and HIV) according to national guidelines. Aim To determine young adults’ opinions of receiving a broader sexual health offer of 3Cs and HIV at their GP practice. Design and setting Qualitative interviews were conducted in a general practice setting in England between March and June 2013. Method Thirty interviews were conducted with nine male and 21 female patients aged 16–24 years, immediately before or after a routine practice attendance. Data were transcribed verbatim and analysed using a thematic framework. Results Participants indicated that the method of testing, timing, and the way the staff member approached the topic were important aspects to patients being offered 3Cs and HIV. Participants displayed a clear preference for 3Cs and HIV to be offered at the GP practice over other sexual health service providers. Participants highlighted convenience of the practice, assurance of confidentiality, and that the sexual health discussion was appropriate and routine. Barriers identified for patients were embarrassment, unease, lack of time, religion, and patients believing that certain patients could take offence. Suggested facilitators include raising awareness, reassuring confidentiality, and ensuring the offer is made in a professional and non-judgemental way at the end of the consultation. Conclusion General practice staff should facilitate patients’ preferences by ensuring that 3Cs and HIV testing services are made available at their surgery and offered to appropriate patients in a non-judgemental way.

Qualitative interviews with healthcare staff in four European countries to inform adaptation of an intervention to increase chlamydia testing

Objective To determine the needs of primary healthcare general practice (GP) staff, stakeholders and trainers to inform the adaptation of a locally successful complex intervention (Chlamydia Intervention Randomised Trial (CIRT)) aimed at increasing chlamydia testing within primary healthcare within South West England to three EU countries (Estonia, France and Sweden) and throughout England. Design Qualitative interviews. Setting European primary healthcare in England, France, Sweden and Estonia with a range of chlamydia screening provision in 2013. Participants 45 GP staff, 13 trainers and 18 stakeholders. Interviews The iterative interview schedule explored participants’ personal attitudes, subjective norms and perceived behavioural controls around provision of chlamydia testing, sexual health services and training in general practice. Researchers used a common thematic analysis. Results Findings were similar across all countries. Most participants agreed that chlamydia testing and sexual health services should be offered in general practice. There was no culture of GP staff routinely offering opportunistic chlamydia testing or sexual health advice, and due to other priorities, participants reported this would be challenging. All participants indicated that the CIRT workshop covering chlamydia testing and sexual health would be useful if practice based, included all practice staff and action planning, and was adequately resourced. Participants suggested minor adaptations to CIRT to suit their country’s health services. Conclusions A common complex intervention can be adapted for use across Europe, despite varied sexual health provision. The intervention (ChlamydiA Testing Training in Europe (CATTE)) should comprise: a staff workshop covering sexual health and chlamydia testing rates and procedures, action planning and patient materials and staff reminders via computer prompts, emails or newsletters, with testing feedback through practice champions. CATTE materials are available at: www.STItraining.eu.

Qualitative impact assessment of an educational workshop on primary care practitioner attitudes to NICE HIV testing guidelines

Background In 2013, Public Health England piloted the ‘3Cs (chlamydia, contraception, condoms) and HIV (human immunodeficiency virus)’ educational intervention in 460 GP surgeries. The educational HIV workshop aimed to improve the ability and confidence of staff to offer HIV testing in line with national guidelines. Aim To qualitatively assess the impact of an educational workshop on GP staff’s attitudes to NICE HIV testing guidelines. Design & setting Qualitative interviews with GP staff across England before and after an educational HIV workshop. Method Thirty-two GP staff (15 before and 17 after educational HIV workshop) participated in interviews exploring their views and current practice of HIV testing. Interview transcripts were thematically analysed and examined, using the components of the theory of planned behaviour (TPB) and normalisation process theory (NPT) as a framework. Results GPs reported that the educational HIV workshop resulted in increased knowledge of, and confidence to offer, HIV tests based on indicator conditions. However, overall participants felt they needed additional HIV training around clinical care pathways for offering tests, giving positive HIV results, and current treatments and outcomes. Participants did not see a place for point-of-care testing in general practice. Conclusion Implementation of national HIV guidelines will require multiple educational sessions, especially to implement testing guidelines for indicator conditions in areas of low HIV prevalence. Additional role-play or discussions around scripts suggesting how to offer an HIV test may improve participants’ confidence and facilitate increased testing. Healthcare assistants (HCAs) may need specific training to ensure that they are skilled in offering HIV testing within new patient checks.

P100 Exploring why a complex intervention piloted in general practices did not result in an increase in chlamydia screening and diagnosis: a qualitative evaluation using the fidelity of implementation model

Background To facilitate opportunistic chlamydia screening in general practices, a complex intervention (3Cs and HIV), based on the previously successful CIRT trial, was implemented across England. The intervention, to encourage practice staff to routinely offer chlamydia testing, only increased chlamydia screening in larger practices or in those offered incentives. Aims a) Explore why the modified intervention did not increase screening across all general practices. b) Suggest recommendations for future intervention implementation. Methods Phone interviews were carried out with 26 GP staff exploring their opinions on the workshops and intervention implementation in practice. Interview transcripts were thematically analysed and further examined using the fidelity of implementation model. Results Participants were positive about the workshops but attendee numbers were low. Often, the intervention content was not adhered to: practice staff were unaware of any on-going trainer support; computer prompts were only added to the female contraception template; patients were not encouraged to complete the test immediately; and videos and posters were not utilised, as suggested. Staff reported that financial incentives, themselves, were not a motivator; competing priorities and time were identified as major barriers. Conclusions Not adhering to the exact intervention model may explain the lack of significant increases in chlamydia screening. To increase fidelity of implementation and consequently improve likelihood of increased screening, the intervention needs to have: more specific action planning; computer prompts added to systems and used; all staff attend the workshop; and on-going practice staff support.

P111 Perceptions of Chlamydia screening, contraception and HIV testing among 16–24 year old patients visiting a GP surgery

Background A complex intervention based on the Theory of Planned Behaviour significantly increased chlamydia screening in general practice (McNulty et al 2014). It may be more beneficial to extend this intervention to a broader sexual health offer including chlamydia testing, contraception advice and when appropriate, HIV testing (3Cs and HIV). Aim To determine young adults’ opinions of having a broader sexual health offer (3Cs and HIV) at their GP practice. Methods Thirty interviews were conducted with 9 male and 21 female patients, 16–24 years in English GP practices. Participants were interviewed immediately before or after a routine practice attendance of any type. Data was analysed using a thematic framework and using QSR Nvivo 10. Results Participants indicated that method of testing, timing and staff member approach were important aspects to chlamydia screening and contraception discussions. Participants displayed a clear preference for the GP practice over other sexual health service locations. Items most important to participants were convenience, reassurance, and that the sexual health discussion is appropriate and routine. Barriers identified were embarrassment, unease, lack of time, religion and concern of causing offence. Suggested facilitators include raising awareness, reassuring confidentiality, ensuring the discussion is facilitated by trust and professionalism at the end of the consultation. Conclusion The majority of participants are happy to be offered 3Cs and HIV at their GP surgery. Therefore, it is important for GP staff to recognise these preferences and ensure that the full 3Cs and HIV services are made available and offered to appropriate patients.

Service evaluation of a pilot to improve primary care sexual health services in England implemented using a stepped wedge design

Abstract Background Sexual health service provision in primary care is an essential component to universal provision of sexual and reproductive health services. However the offer of these services is not consistent. The 3Cs & HIV was a national pilot that combined educational workshops with posters, testing performance feedback, and continuous support from a specialist trainer. The aim was to improve awareness and skills of staff to increase rates of chlamydia screening in the population at highest risk (men and women aged 15–24 years) and to provide condoms with contraceptive information plus HIV testing according to national guidelines. Methods The pilot used a stepped wedge design over three phases from Aug 1, 2013, to Sept 30, 2014. Chlamydia testing and diagnosis rates in the control (pretraining) and intervention (post-training) periods were compared by use of a multivariable negative binomial regression model with general practice fitted as a random effect. Owing to the stepped wedge design, the number of months contributing to the control and intervention periods differed depending on which phase the general practice was allocated to and when the practice received training. Characteristics of general practices participating were included in the model. Practices were not paid for the intervention. The Research Governance Coordinator for Public Health England confirmed that no ethics approvals were needed for this study. Findings The 460 participating practices conducted 26 021 tests in the control period and 18 797 tests during the intervention period. Intention-to-treat analysis showed decreased median number of tests and diagnoses per month per practice after receiving training (2·68 tests before training [IQR 1·00–4·77] vs 2·67 after training [1·10–4·90]; 0·14 diagnoses before training [0–0·30] vs 0·13 after training [0–0·27]). Adjusted multivariable regression analysis showed no significant change in overall testing or diagnoses (incidence rate ratio [IRR] 1·01, 95% CI 0·96–1·07 and 0·98, 0·84–1·15, respectively). Testing increased significantly in 148 practices where payment was already in place before the intervention (IRR 2·12, 95% CI 1·41–3·18). Interpretation This large national pilot found that educational support sessions to increase chlamydia screening in primary care were only effective in practices that already receive payment for chlamydia screening. 3Cs & HIV training might be a useful way to make better use of the resources already available. However this intervention will not increase national testing rates substantially. Although increases found in subgroups were statistically significant, they were still relatively small in magnitude. Funding The 3Cs & HIV pilot was funded by Public Health England and was part of the Chlamydia Testing Training in Europe (CATTE) project. CATTE is part funded by a Leonardo Transfer of Innovation grant as part of European Union Lifelong Learning Programme.