Needle in a haystack: the yield of syphilis outreach screening at 5 US sites-2000 to 2007

Costs of Identifying Cases of Syphilis Using Rapid Syphilis Tests in Multiple Nonclinical Settings in the United States

BACKGROUND

Outreach screening is a common strategy for detecting cases of syphilis in high-risk populations. New rapid syphilis tests allow for quicker response times and may alter the costs of detecting and treating syphilis in nonclinical settings.

METHODS

Between May and October of 2017, we collected detailed retrospective cost data from 2 outreach screening programs engaging people experiencing homelessness and LGBTQ populations. Comprehensive and retrospective cost information, disaggregated by cost category, programmatic activity, and source of support, was collected during and after the testing period.

RESULTS

Across all sites, rapid syphilis tests were conducted on 595 people at an average cost of $213 per person. Twenty-three cases of syphilis were confirmed and treated for an average cost of $5517 per case, ranging from $3604 at a rehabilitation facility to $13,140 at LGBTQ venues served by a mobile clinic. Personnel contributed the most to total costs (56.4%), followed by supplies (12.8%) and the use of buildings (10.4%). Expenditures by programmatic activity varied substantially across sites.

CONCLUSIONS

Testing costs varied between venues, reflecting differences in the models used and intensity of services provided. Although staff costs are the major driver, buildings and supplies costs are also significant. Our findings suggest that outreach screenings using rapid syphilis tests may be a feasible and cost-effective tool for health departments when targeting known high-prevalence areas and hard-to-reach populations.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Evaluation of the Lumipulse G TP-N Chemiluminescent Immunoassay as a Syphilis Screening Test

A syphilis diagnosis is often aided by the detection of treponemal and nontreponemal antibodies. Automated treponemal antibody detection systems enable high-volume clinical laboratories to perform syphilis screening at a faster pace with lower labor costs. The Lumipulse G TP-N chemiluminescent immunoassay is an automated system that qualitatively detects IgG and IgM antibodies against Treponema pallidum antigens in human serum and plasma. To assess performance characteristics and workflow efficiency, the Lumipulse G TP-N assay was compared to the Bioplex 2200 Syphilis IgG multiplex flow immunoassay. Among the 4,134 routine and HIV samples tested by the two automated assays, the percentage of agreement was excellent at 99.0% (95% confidence interval [CI], 98.6% to 99.2%; κ, 0.89), with the Lumipulse G TP-N having a shorter time to first and subsequent results. All specimens with reactive syphilis screening results were further tested by rapid plasma reagin (RPR) and Treponema pallidum particle agglutination (TP·PA) testing (n = 231). The results from the RPR-reactive samples (n = 82) showed complete concordance with the two automated assays, while the TP·PA assay displayed some discrepancies. The positive percent agreement (PPA) and negative percent agreement (NPA) between the TP·PA test and the Lumipulse G TP-N test were 98.9% and 77.3%, respectively. The Bioplex 2200 Syphilis IgG immunoassay displayed a similar PPA (100%) but a substantially lower NPA (15.9%). Patient chart reviews of discrepant results suggested that the Lumipulse G TP-N assay produced 27 fewer falsely reactive results and can reduce the amount of additional confirmatory RPR and TP·PA testing needed. The analogous performance characteristics of the two automated systems indicate that the Lumipulse G TP-N assay is suitable for high-throughput syphilis screening.

Bacterial Sexually Transmitted Disease Screening Outside the Clinic--Implications for the Modern Sexually Transmitted Disease Program

BACKGROUND

The development of noninvasive nucleic acid amplification tests for chlamydia and gonorrhea has facilitated innovation in moving sexually transmitted disease (STD) screening to nonclinical settings. However, limited data are available to inform local STD programs on evidence-based approaches to STD screening in nonclinical settings in the United States.

METHODS

We conducted a systematic review of the literature published since 2000 related to chlamydia, gonorrhea, and syphilis screening in US correctional settings, bathhouses and sex venues, self-collected at-home testing, and other nonclinical sites.

RESULTS

Sixty-four articles met eligibility criteria and were reviewed. Although data on testing volume and positivity were available, there were scarce data on the proportion of new positives treated and the programmatic costs for the various screening programs. Screening in correctional settings identified a sizable amount of asymptomatic infections. The value and sustainability of screening in the other nonclinical settings examined was not clear from the published literature.

CONCLUSIONS

Local and state health departments should explore the development of sustainable jail and juvenile detention screening programs for STDs. Furthermore, local programs should pilot outreach and home-based STD screening programs to determine if they are identifying asymptomatic persons who would not have otherwise been found. Local programs are encouraged to present and publish their findings related to non-clinic-based screening to enhance the limited body of literature; data on the proportion of new infections treated and the local program costs are needed.

Emerging trends and persistent challenges in the management of adult syphilis

There are an estimated 10.6 million incident cases of syphilis worldwide each year. We highlight some persistent challenges and emerging trends in the clinical management of syphilis with a particular focus on therapy, serology, diagnostics, and prevention. Decades after the introduction of penicillin, the optimal management of early syphilis continues to be a controversial topic, particularly in the setting of HIV co-infection. Similarly, the need for routine lumbar puncture in HIV co-infected asymptomatic persons is an unanswered question. Despite advances in both automation and point-of-care diagnostics, we continue to rely on indirect measures of disease activity to manage this infection. As syphilis rates in some populations continue to rise, novel and effective prevention strategies are needed.

Previously undiagnosed HIV infections identified through cluster investigation, North Carolina, 2002-2007

During cluster investigation, index patients name social contacts that are not sex or drug-sharing partners. The likelihood of identifying new HIV infections among social contacts is unknown. We hypothesized greater odds of identifying new infections among social contacts identified by men who report sex with men (MSM). We reviewed North Carolina HIV diagnoses during 2002-2005 and used logistic regression to compare testing results among social contacts of MSM, men who report sex with women only (MSW) and women. HIV was newly diagnosed among 54/601 (9.0 %) social contacts tested named by MSM, 16/522 (3.1 %) named by MSW, and 23/639 (3.6 %) named by women. Compared with those named by MSW, odds of new HIV diagnosis were greater among MSM social contacts (adjusted odds ratio: 2.5; 95 % confidence interval: 1.3-4.7). Testing social contacts identified previously undiagnosed HIV infections and could provide an opportunity to interrupt transmission.

Public health interventions to control syphilis

Syphilis control strategies are old, but interventions have changed and there is now a more scientific approach to evidence of effectiveness. We searched PubMed using 'syphilis control' to identify papers that measured the effectiveness of interventions. We also included novel approaches and comprehensive responses to outbreaks. Few papers used high-quality research methodology and fewer evaluated impact on prevalence or incidence; most assessed intermediate outcomes. Syphilis can often be controlled by a combination of case finding, treatment and education. However, outbreaks are unique and ongoing evaluation is needed to see if interventions are producing intended intermediate outcomes at reasonable costs.