The Impact of Screening and Partner Notification on Chlamydia Prevalence and Numbers of Infections Averted in the United States, 2000-2015: Evaluation of Epidemiologic Trends Using a Pair-Formation Transmission Model

Revealing the Genetic Diversity of Chinese Chlamydia trachomatis Strains Directly From Clinical Samples Through Selective Whole Genome Amplification

BACKGROUND

Chlamydia trachomatis is the causative agent of the most prevalent bacterial sexually transmitted infections globally. Whole genome sequencing is essential for molecular Chlamydia surveillance; however, its application is hampered by the pathogen's low abundance in clinical specimens and the expensive labor-intensive nature of existing enrichment methodologies for Chlamydia.

METHODS

We developed a targeted whole genome amplification tool termed SWITCH by integrating phi29 DNA polymerase-mediated amplification with meticulously designed primer sets to enrich the C trachomatis genome, followed by whole genome sequencing. This method underwent evaluation through testing synthetic and clinical specimens.

RESULTS

SWITCH demonstrated robust ability to achieve up to 98.3% genomic coverage of C trachomatis from as few as 26.4 genomic copies present in synthetic specimens, and it exhibited excellent performance across diverse C trachomatis serovars. Utilizing SWITCH, we directly generated 21 Chlamydia genomes from 26 clinical samples, enabling us to gain insights into the genetic relationships and phylogeny of current Chlamydia strains circulating in the country. Remarkably, this study marked the first instance of generating Chinese Chlamydia genomes directly from clinical samples.

CONCLUSIONS

SWITCH represents a practical cost-efficient approach to enrich the Chlamydia genome directly from clinical specimens, offering an efficient avenue for molecular surveillance of Chlamydia.

Claims for Contraceptive Services and Chlamydia and Gonorrhea Testing Among Insured Adolescent and Young Adult Females in the United States

Objective: To examine claims for reversible prescription contraceptives and chlamydia and gonorrhea testing among commercially and Medicaid-insured adolescent and young adult (AYA) females in the United States. Methods: Using IBM MarketScan Research Databases, we identified sexually active, nonpregnant AYA (15- to 24-year-old) females enrolled in 2018. We examined claims for reversible prescription contraceptives and chlamydia and gonorrhea testing, using drug names and diagnosis/procedure codes, by age-group in commercially and Medicaid-insured separately and by race/ethnicity in Medicaid-insured. Results: Among 15- to 19-year-old and 20- to 24-year-old females, 67.2% and 67.9% of commercially insured and 57.3% and 54.0% of Medicaid-insured, respectively, had claims for reversible prescription contraceptives in 2018. Across insurance types among both age-groups, the most common claim for contraceptives was prescription for combined oral contraceptives. Among Medicaid-insured 15- to 19-year-olds, claims for contraceptives ranged from 42.6% for Hispanic females to 63.4% for non-Hispanic White females; among Medicaid-insured 20- to 24-year-olds, claims ranged from 50.4% for non-Hispanic Black females to 57.0% for non-Hispanic White females. Approximately half of the commercially and Medicaid-insured females had claims for chlamydia and gonorrhea testing. Non-Hispanic Black females had the highest percentages of claims for chlamydia testing (56.3% among 15- to 19-year-olds and 61.1% among 20- to 24-year-olds) and gonorrhea testing (61.6% among 15- to 19-year-olds and 64.9% among 20- to 24-year-olds). Conclusion: Approximately, two-thirds of commercially insured and more than half of Medicaid-insured, sexually active, nonpregnant AYA females had claims for reversible prescription contraceptives. Race/ethnicity data were available for Medicaid-insured females, and there were differences in claims for contraceptives and chlamydia and gonorrhea testing by race/ethnicity. Half of the AYA females had claims for chlamydia and gonorrhea testing suggesting missed opportunities.

Costs, Health Benefits, and Cost-Effectiveness of Chlamydia Screening and Partner Notification in the United States, 2000-2019: A Mathematical Modeling Analysis

BACKGROUND

Chlamydia remains a significant public health problem that contributes to adverse reproductive health outcomes. In the United States, sexually active women 24 years and younger are recommended to receive annual screening for chlamydia. In this study, we evaluated the impact of estimated current levels of screening and partner notification (PN), and the impact of screening based on guidelines on chlamydia associated sequelae, quality adjusted life years (QALYs) lost and costs.

METHODS

We conducted a cost-effectiveness analysis of chlamydia screening, using a published calibrated pair formation transmission model that estimated trends in chlamydia screening coverage in the United States from 2000 to 2015 consistent with epidemiological data. We used probability trees to translate chlamydial infection outcomes into estimated numbers of chlamydia-associated sequelae, QALYs lost, and health care services costs (in 2020 US dollars). We evaluated the costs and population health benefits of screening and PN in the United States for 2000 to 2015, as compared with no screening and no PN. We also estimated the additional benefits that could be achieved by increasing screening coverage to the levels indicated by the policy recommendations for 2016 to 2019, compared with screening coverage achieved by 2015.

RESULTS

Screening and PN from 2000 to 2015 were estimated to have averted 1.3 million (95% uncertainty interval [UI] 490,000-2.3 million) cases of pelvic inflammatory disease, 430,000 (95% UI, 160,000-760,000) cases of chronic pelvic pain, 300,000 (95% UI, 104,000-570,000) cases of tubal factor infertility, and 140,000 (95% UI, 47,000-260,000) cases of ectopic pregnancy in women. We estimated that chlamydia screening and PN cost $9700 per QALY gained compared with no screening and no PN. We estimated the full realization of chlamydia screening guidelines for 2016 to 2019 to cost $30,000 per QALY gained, compared with a scenario in which chlamydia screening coverage was maintained at 2015 levels.

DISCUSSION

Chlamydia screening and PN as implemented in the United States from 2000 through 2015 has substantially improved population health and provided good value for money when considering associated health care services costs. Further population health gains are attainable by increasing screening further, at reasonable cost per QALY gained.

Developing Sentinel Surveillance for Chlamydia and Gonorrhea Using Test Results From Routine Screening During Pregnancy

Background.

Interpretation of case-based surveillance of chlamydia and gonorrhea is limited by the lack of negative tests for comparison. We sought to develop a sustainable electronic health record (EHR)-based approach to disease surveillance in a sentinel population of pregnant persons.

Methods.

We conducted a one-year assessment of sexually transmitted infections (STIs) in persons receiving at least one pregnancy-related visit within our university medical center. Data were obtained using EHR analytic structured query language code (SQL). Patients were categorized by whether they had an STI test during pregnancy and if screened, by the STI test results (positive or negative). We assessed screening and positivity by demographic using bivariate analyses. Predictors of a positive STI test were determined using logistic regression.

Results.

We identified 4,553 persons who received pregnancy care from January 1 to December 31, 2021. Seventy-six percent (n, 3483) of persons were screened for an STI during pregnancy. Those who identified as white or had private insurance were less likely to have a chlamydia test. Among persons screened, Trichomonas was the most commonly detected STI (5%, 141/2,698) followed by chlamydia (4%, 135/3,456), and gonorrhea (0.7% 24/3,468). Predictors of a positive STI test during pregnancy were Black race [adjusted odds ratio (aOR) 6.0 (95% Confidence Interval 4.2–8.7)], age ≤ 25 [aOR 2.5 (1.9–3.3)], and public insurance [aOR 1.6 (1.2–2.1)].

Conclusions.

We demonstrated that EHRs can be utilized to assess gonorrhea and chlamydia positivity. These methods could potentially be applied in other jurisdictions to improve the understanding of national STI surveillance.

Electronic health records of a sentinel population of pregnant persons were queried to perform STI surveillance. This approach may improve the accuracy of national case estimates of STIs.

If We Make It, Will They Take It? Attitudes Toward the Acceptability of Chlamydia Point-of-Care Testing Among Adolescents and Young Adults

BACKGROUND

Adolescent women, 15 to 19 years of age, have the highest rate of Chlamydia trachomatis infection in the United States. The objective of this study was to ascertain knowledge and experience of C. trachomatis and acceptance of C. trachomatis point-of-care testing (POCT) if made available over-the-counter (OTC). Currently, there are no tests for C. trachomatis available OTC for purchase.

METHODS

Patients attending adolescent clinics at University Hospital of Brooklyn and Kings County Hospital received an anonymous 12-item questionnaire. Both clinics serve predominantly African and Caribbean American urban populations. Questions included demographics, sexual orientation, chlamydia knowledge, testing history, prior infection, partner notification, and acceptance of OTC POCT for C. trachomatis.

RESULTS

Surveys from 151 patients (116 women, 35 men) aged 12 to 21 years (mean age, 17.6 years) were analyzed. Only 34 of the 151 (22.5%) respondents understood C. trachomatis transmission; 31 (20.5%) knew its complications. Sixty-seven (44.4%) would purchase an OTC test but 101 (66.8%) would pay no more than $20. All 151 patients reported that they would follow-up with doctor if positive; 143 (94.7%) would notify partners, although 5 of the 31 (16.1%) women with prior infection did not notify partners.

CONCLUSIONS

Nearly half (44%) of adolescents in our population would be interested in using a potential OTC test for C. trachomatis. Cost was a major disincentive. Knowledge of infection remains cursory. However, those with a history of C. trachomatis infection and familiar with its complications were more interested in purchasing a home test. Although 100% of the respondents reported that they would follow-up with their physician if they tested positive, past behavior suggests that partner notification might be suboptimal.

Impact of Check It: A Novel Community-Based Chlamydia Screening and Expedited Treatment Program for Young Black Men

OBJECTIVES

This study aimed to estimate the impact of the Check It program, a novel community-based chlamydia seek, test, and treat program for young Black men who have sex with women, on test positivity rates for chlamydia in young Black women.

METHODS

We used a synthetic control model to compare chlamydia test positivity rates in Orleans Parish (intervention site) with other similar parishes (control sites) in Louisiana. We estimated a model that used all other parishes as potential contributors to a synthetic control for Louisiana as well as a sample limited to the 40 parishes in Louisiana with the largest Black populations.

RESULTS

The Check It program was associated with a 1.69-percentage-point decline in chlamydia positivity in the first full year of operation and a 2.44-percentage-point decline in chlamydia positivity in the second full year of operation compared with control sites with the largest Black populations (P = 0.05). Results were similar when the treatment site was compared with all other sites in Louisiana.

CONCLUSIONS

The Check It program was associated with a significant decline in chlamydia testing positivity rates among women in Orleans Parish compared with control sites. Screening of young Black men who have sex with women can decrease rates in women living in the same community. Future recommendations for chlamydia screening of young men should be considered.

Cost-effectiveness of Check It: A Novel Community-Based Chlamydia Screening and Expedited Treatment Program for Young Black Men

Background

We assessed the cost-effectiveness of the Check It program, a novel community-based chlamydia screening and expedited partner treatment program for young Black men conducted in New Orleans since 2017.

Methods

We implemented a probabilistic cost-effectiveness model using a synthetic cohort of 16 181 men and 13 419 women intended to simulate the size of the Black, sexually active population in New Orleans ages 15–24 years.

Results

The Check It program cost $196 838 (95% confidence interval [CI]: $117 320–$287 555) to implement, saved 10.2 quality-adjusted life-years (QALYs; 95% CI: 7.7–12.7 QALYs), and saved $140 950 (95% CI: −$197 018 to −$105 620) in medical costs per year. The program cost $5468 (95% CI: cost saving, $16 717) per QALY gained. All iterations of the probabilistic model returned cost-effectiveness ratios less than $50 000 per QALY gained.

Conclusions

The Check It program (a bundled seek, test, and treat chlamydia prevention program for young Black men) is cost-effective under base case assumptions. Communities where Chlamydia trachomatis rates have not declined could consider implementing a similar program.

A Systematic Review of New Approaches to Sexually Transmitted Infection Screening Framed in the Capability, Opportunity, Motivation, and Behavior Model of Implementation Science

ABSTRACT

Chlamydia and gonorrhea are 2 of the most common bacterial sexually transmitted infections (STIs) worldwide. Rising chlamydia and gonorrhea rates along with increased closing of STI clinics has led many to seek STI testing in clinical settings such as urgent cares and walk-in clinics. However, with competing priorities, providing effective and efficient STI care can be difficult in these settings. This has left a growing need for the implementation of novel STI screening programs in other clinical settings. This review summarizes previous studies that have evaluated the clinical implementation of chlamydia and gonorrhea screening programs in these settings. Literature from January 2015 to February 2020 regarding the implementation or evaluation of STI screening programs in clinical settings was reviewed. Constructs from the Capability, Opportunity, Motivation, and Behavior model were used to organize results, as this model can aid in identifying specific strategies for behavior/process change interventions. We found that multiple STI screening programs have been implemented and evaluated in 5 different countries and multiple health care facilities including sexual health clinics, urgent cares, walk-in clinics, and university health clinics. When implementing new STI screening programs, sample-first, test-and-go services and molecular point-of-care (POC) testing approaches were found to be effective in increasing screening and reducing costs and time to treatment. At the health care systems level, these programs can help reduce STI screening costs and generate additional revenue for clinics. At the provider level, clear communication and guidance can help clinical and administrative staff in adopting new screening programs. Finally, at the patient level, new programs can reduce time to treatment and travel costs in visiting clinics multiple times for testing and treatment services.

The Influence of Screening, Misclassification, and Reporting Biases on Reported Chlamydia Case Rates Among Young Women in the United States, 2000 Through 2017

BACKGROUND

National chlamydia case rate trends are difficult to interpret because of biases from partial screening coverage, imperfect diagnostic tests, and underreporting. We examined the extent to which these time-varying biases could influence reported annual chlamydia case rates.

METHODS

Annual reported case rates among women aged 15 through 24 years from 2000 through 2017 were obtained from the Centers for Disease Control and Prevention's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention AtlasPlus tool. Estimates of reporting completeness, diagnostic test sensitivity and specificity, and screening coverage were derived from literature review and expert opinion. We adjusted annual reported case rates for incomplete reporting, imperfect diagnostic tests, and partial screening coverage through a series of corrections, and calculated annual adjusted case rates of correctly diagnosed chlamydia.

RESULTS

Adjusted chlamydia case rates among young women were higher than reported case rates throughout the study period. Reported case rates increased over the study period, but adjusted rates declined from 12,900 to 7900 cases per 100,000 person-years between 2000 and 2007. After 2007, adjusted case rates declined to 7500 cases per 100,000 person-years in 2017. Bias from partial screening coverage had a larger impact on case rate magnitude and trend shape than bias from imperfect diagnostic tests or underreporting.

CONCLUSIONS

Reported chlamydia case rates may be substantially lower than true chlamydia case rates because of incomplete reporting, imperfect diagnostic tests, and partial screening coverage. Because the magnitude of these biases has declined over time, the differences between reported and adjusted case rates have narrowed, revealing a sharp decline in adjusted case rates even as reported case rates have risen. The decline in adjusted case rates suggests that the rise in reported case rates should not be interpreted strictly as increasing chlamydia incidence, as the observed rise can be explained by improvements in screening coverage, diagnostic tests, and reporting.

The Estimated Lifetime Medical Cost of Chlamydia, Gonorrhea, and Trichomoniasis in the United States, 2018

BACKGROUND

The purpose of this study was to provide updated estimates of the average lifetime medical cost per infection for chlamydia, gonorrhea, and trichomoniasis.

METHODS

We adapted a published decision tree model that allowed for 7 possible outcomes of infection: (1) symptomatic infection, treated, no sequelae; (2) symptomatic infection, not treated, sequelae; (3) symptomatic infection, not treated, no sequelae; (4) asymptomatic infection, treated, sequelae; (5) asymptomatic infection, treated, no sequelae; (6) asymptomatic infection, not treated, sequelae; and (7) asymptomatic infection, not treated, no sequelae. The base case values and ranges we applied for the model inputs (i.e., the probability and cost assumptions) were based on published studies.

RESULTS

The estimated lifetime medical costs per infection for men and women, respectively, were $46 (95% credibility interval, $32-$62) and $262 ($127-$483) for chlamydia, $78 ($36-$145) and $254 ($96-$518) for gonorrhea, and $5 ($1-$14) and $36 ($17-$58) for trichomoniasis. Cost estimates for men were most sensitive to assumptions regarding the probability that the infection is symptomatic, the probability of treatment if asymptomatic, and the cost of treatment of infection. Cost estimates for chlamydia and gonorrhea in women were most sensitive to assumptions regarding the probability and cost of subsequent pelvic inflammatory disease.

CONCLUSIONS

These estimates of the lifetime medical cost per infection can inform updated estimates of the total annual cost of sexually transmitted infections in the United States, as well as analyses of the value and cost-effectiveness of sexually transmitted infection prevention interventions.

The Estimated Direct Lifetime Medical Costs of Sexually Transmitted Infections Acquired in the United States in 2018

BACKGROUND

We estimated the lifetime medical costs attributable to sexually transmitted infections (STIs) acquired in 2018, including sexually acquired human immunodeficiency virus (HIV).

METHODS

We estimated the lifetime medical costs of infections acquired in 2018 in the United States for 8 STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, and HIV. We limited our analysis to lifetime medical costs incurred for treatment of STIs and for treatment of related sequelae; we did not include other costs, such as STI prevention. For each STI, except HPV, we calculated the lifetime medical cost by multiplying the estimated number of incident infections in 2018 by the estimated lifetime cost per infection. For HPV, we calculated the lifetime cost based on the projected lifetime incidence of health outcomes attributed to HPV infections acquired in 2018. Future costs were discounted at 3% annually.

RESULTS

Incident STIs in 2018 imposed an estimated $15.9 billion (25th-75th percentile: $14.9-16.9 billion) in discounted, lifetime direct medical costs (2019 US dollars). Most of this cost was due to sexually acquired HIV ($13.7 billion) and HPV ($0.8 billion). STIs in women accounted for about one fourth of the cost of incident STIs when including HIV, but about three fourths when excluding HIV. STIs among 15- to 24-year-olds accounted for $4.2 billion (26%) of the cost of incident STIs.

CONCLUSIONS

Incident STIs continue to impose a considerable lifetime medical cost burden in the United States. These results can inform health economic analyses to promote the use of cost-effective STI prevention interventions to reduce this burden.

Potential for Point-of-Care Tests to Reduce Chlamydia-associated Burden in the United States: A Mathematical Modeling Analysis

Background

Point-of-care testing (POCT) assays for chlamydia are being developed. Their potential impact on the burden of chlamydial infection in the United States, in light of suboptimal screening coverage, remains unclear.

Methods

Using a transmission model calibrated to data in the United States, we estimated the impact of POCT on chlamydia prevalence, incidence, and chlamydia-attributable pelvic inflammatory disease (PID) incidence, assuming status quo (Analysis 1) and improved (Analysis 2) screening frequencies. We tested the robustness of results to changes in POCT sensitivity, the proportion of patients getting treated immediately, the baseline proportion lost to follow-up (LTFU), and the average treatment delay.

Results

In Analysis 1, high POCT sensitivity was needed to reduce the chlamydia-associated burden. With a POCT sensitivity of 90%, reductions from the baseline burden only occurred in scenarios in which over 60% of the screened individuals would get immediate treatment and the baseline LTFU proportion was 20%. With a POCT sensitivity of 99% (baseline LTFU 10%, 2-week treatment delay), if everyone were treated immediately, the prevalence reduction was estimated at 5.7% (95% credible interval [CrI] 3.9–8.2%). If only 30% of tested persons would wait for results, the prevalence reduction was only 1.6% (95% CrI 1.1–2.3). POCT with 99% sensitivity could avert up to 12 700 (95% CrI 5000–22 200) PID cases per year, if 100% were treated immediately (baseline LTFU 20% and 3-week treatment delay). In Analysis 2, when POCT was coupled with increasing screening coverage, reductions in the chlamydia burden could be realized with a POCT sensitivity of 90%.

Conclusions

POCT could improve chlamydia prevention efforts if test performance characteristics are significantly improved over currently available options.

Mathematical modeling study of school-based chlamydia screening: potential impact on chlamydia prevalence in intervention schools and surrounding communities

Background

Chlamydia screening in high schools offers a way to reach adolescents outside of a traditional clinic setting. Using transmission dynamic modeling, we examined the potential impact of high-school-based chlamydia screening programs on the burden of infection within intervention schools and surrounding communities, under varying epidemiological and programmatic conditions.

Methods

A chlamydia transmission model was calibrated to epidemiological data from three different settings. Philadelphia and Chicago are two high-burden cities with existing school-based screening programs. Rural Iowa does not have an existing program but represents a low-burden setting. We modeled the effects of the two existing programs to analyze the potential influence of program coverage and student participation. All three settings were used to examine a broader set of hypothetical programs with varying coverage levels and time trends in participation.

Results

In the modeled Philadelphia program, prevalence among the intervention schools’ sexually active 15–18 years old population was 4.34% (95% credible interval 3.75–4.71%)after 12 program years compared to 5.03% (4.39–5.43%) in absence of the program. In the modeled Chicago program, prevalence was estimated as 5.97% (2.60–7.88%) after 4 program years compared to 7.00% (3.08–9.29%) without the program. In the broader hypothetical scenarios including both high-burden and low-burden settings, impact of school-based screening programs was greater in absolute terms in the higher-prevalence settings, and benefits in the community were approximately proportional to population coverage of intervention schools. Most benefits were garnered if the student participation did not decline over time.

Conclusions

Sustained high student participation in school-based screening programs and broad coverage of schools within a target community are likely needed to maximize program benefits in terms of reduced burden of chlamydia in the adolescent population.

High Willingness to Participate in Partner Notification among Women Attending Reproductive Health and STI Clinics in Shenzhen, China: A Cross-Sectional Study

Genital Chlamydia trachomatis (CT) is one of the most common sexually transmitted infections (STI) worldwide. We explored the factors associated with willingness to participate in partner notification (PN) among women attending reproductive health and STI clinics in Shenzhen, China. An anonymous questionnaire was used to collect the sociodemographic characteristics, STI histories, and willingness to participate in routine CT screening and partner notification. In total, 87.31% (n = 10,780) of participants were willing to notify their sex partner(s) if they were diagnosed with a CT infection. Willingness to complete PN was significantly associated with: being married, residing in Shenzhen ≥1 year, having completed junior college or higher, not currently reporting STI-related symptoms, willing to have routine CT screening, and having a correct understanding of the health sequelae of CT infection. Nearly all women surveyed at reproductive health and STI clinics in Shenzhen reported willingness to complete PN. Promoting PN in these settings could help detect a large number of additional CT cases. Our findings provide evidence and implications for public health interventions on PN and suggest that targeted interventions are urgently needed for particular subpopulations including those not currently married, with shorter residency, lower education, and less awareness about the dangers of CT infection.

Diagnosing sexually transmitted infections in resource-constrained settings: challenges and ways forward

INTRODUCTION

Sexually transmitted infections (STIs) remain prevalent and are increasing in several populations. Appropriate STI diagnosis is crucial to prevent the transmission and sequelae of untreated infection. We reviewed the diagnostic accuracy of syndromic case management and existing point-of-care tests (POCTs), including those in the pipeline, to diagnose STIs in resource-constrained settings.

METHODS

We prioritized updating the systematic review and meta-analysis of the diagnostic accuracy of vaginal discharge from 2001 to 2015 to include studies until 2018. We calculated the absolute effects of different vaginal flowcharts and the diagnostic performance of POCTs on important outcomes. We searched the peer-reviewed literature for previously conducted systematic reviews and articles from 1990 to 2018 on the diagnostic accuracy of syndromic management of vaginal and urethral discharge, genital ulcer and anorectal infections. We conducted literature reviews from 2000 to 2018 on the existing POCTs and those in the pipeline.

RESULTS AND DISCUSSIONS

The diagnostic accuracy of urethral discharge and genital ulcer disease syndromes is relatively adequate. Asymptomatic Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections limit the use of vaginal discharge and anorectal syndromes. The pooled diagnostic accuracy of vaginal syndromic case management for CT/NG is low, resulting in high numbers of overtreatment and missed treatment. The absolute effect of POCTs was reduced overtreatment and missed treatment. Findings of the reviews on syndromic case management underscored the need for low-cost and accurate POCTs for the identification, first, of CT/NG, and, second, of Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) and NG and MG resistance/susceptibility testing. Near-patient POCT molecular assays for CT/NG/TV are commercially available. The prices of these POCTs remain the barrier for uptake in resource-constrained settings. This is driving the development of lower cost solutions.

CONCLUSIONS

The WHO syndromic case management guidelines should be updated to raise the quality of STI management through the integration of laboratory tests. STI screening strategies are needed to address asymptomatic STIs. POCTs that are accurate, rapid, simple and affordable are urgently needed in resource-constrained settings to support the uptake of aetiological diagnosis and treatment.