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McMahon BL, Buitendam E, Symonds M, Estcourt CS, Saunders J. Use of a five-category partner-type classification within a chlamydia and gonorrhoea service evaluation highlights opportunities for targeted partner notification to improve STI control. Sex Transm Infect 2024:sextrans-2024-056108. [PMID: 39237136 DOI: 10.1136/sextrans-2024-056108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 07/17/2024] [Indexed: 09/07/2024] Open
Abstract
OBJECTIVES Partner notification (PN) is a key component of sexually transmitted infection control. British Association for Sexual Health and HIV guidelines now recommend partner-centred PN outcomes using a five-category partner classification (established, new, occasional, one-off, sex worker). We evaluated the reporting of partner-centred PN outcomes in two contrasting UK sexual health services. METHODS Using the electronic patient records of 40 patients with a positive gonorrhoea test and 180 patients with a positive chlamydia test, we extracted PN outcomes for the five most recent sexual contacts within the appropriate lookback period. RESULTS 180 patients with chlamydia reported 262 partners: 220 were contactable (103 established, 9 new, 43 occasional, 52 one-off, 13 unknown/unrecorded). 40 patients with gonorrhoea reported 88 partners: 53 were contactable (7 established, 1 new, 14 occasional, 10 one-off and 21 unknown/not recorded). No sex worker partners were reported. Most established partners of people with chlamydia (96/103) or gonorrhoea (7/7) were notified but fewer (60/103 and 6/7, respectively) attended for testing. Of those, 39 had a positive chlamydia test and two had a positive gonorrhoea test. For both chlamydia and gonorrhoea, most occasional and new partners were reported to be notified but there was a sharper decline in those tested. For both infections, one-off partners had the lowest rates of accessing services and testing. For chlamydia, 81% were notified (42/52), 23% accessed services (12/52) and 21% tested (11/52). However, 91% of those tested were positive (10/11). The number of contactable one-off gonorrhoea contacts was small and few attended. CONCLUSIONS Measuring partner-centred PN outcomes was feasible. There were differences in partner engagement with PN between the different infections and partner types. If these findings are replicated in larger samples, it suggests that interventions to target one-off partners who have low rates of PN engagement yet high levels of positivity could play a key role in reducing infection at population level.
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Affiliation(s)
| | - Erna Buitendam
- Blood Safety, Hepatitis, STIs and HIV Division, UK Health Security Agency, London, UK
| | - Merle Symonds
- West Sussex Health and Social Care NHS Trust, Worthing, UK
| | - Claudia S Estcourt
- Sandyford Sexual Health Service, Glasgow, UK
- Glasgow Caledonian University School of Health and Life Sciences, Glasgow, UK
| | - John Saunders
- Blood Safety, Hepatitis, STIs and HIV Division, UK Health Security Agency, London, UK
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Accelerated partner therapy contact tracing for people with chlamydia (LUSTRUM): a crossover cluster-randomised controlled trial. THE LANCET PUBLIC HEALTH 2022; 7:e853-e865. [DOI: 10.1016/s2468-2667(22)00204-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/26/2022] [Accepted: 08/09/2022] [Indexed: 01/18/2023] Open
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Estcourt CS, Flowers P, Cassell JA, Pothoulaki M, Vojt G, Mapp F, Woode-Owusu M, Low N, Saunders J, Symonds M, Howarth A, Wayal S, Nandwani R, Brice S, Comer A, Johnson AM, Mercer CH. Going beyond 'regular and casual': development of a classification of sexual partner types to enhance partner notification for STIs. Sex Transm Infect 2022; 98:108-114. [PMID: 33927009 PMCID: PMC8862076 DOI: 10.1136/sextrans-2020-054846] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/03/2021] [Accepted: 02/27/2021] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To develop a classification of sexual partner types for use in partner notification (PN) for STIs. METHODS A four-step process: (1) an iterative synthesis of five sources of evidence: scoping review of social and health sciences literature on partner types; analysis of relationship types in dating apps; systematic review of PN intervention content; and review of PN guidelines; qualitative interviews with public, patients and health professionals to generate an initial comprehensive classification; (2) multidisciplinary clinical expert consultation to revise the classification; (3) piloting of the revised classification in sexual health clinics during a randomised controlled trial of PN; (4) application of the Theoretical Domains Framework (TDF) to identify index patients' willingness to engage in PN for each partner type. RESULTS Five main partner types emerged from the evidence synthesis and consultation: 'established partner', 'new partner', 'occasional partner', 'one-off partner' and 'sex worker'. The types differed across several dimensions, including likely perceptions of sexual exclusivity, likelihood of sex reoccurring between index patient and sex partner. Sexual health professionals found the classification easy to operationalise. During the trial, they assigned all 3288 partners described by 2223 index patients to a category. The TDF analysis suggested that the partner types might be associated with different risks of STI reinfection, onward transmission and index patients' engagement with PN. CONCLUSIONS We developed an evidence-informed, useable classification of five sexual partner types to underpin PN practice and other STI prevention interventions. Analysis of biomedical, psychological and social factors that distinguish different partner types shows how each could warrant a tailored PN approach. This classification could facilitate the use of partner-centred outcomes. Additional studies are needed to determine the utility of the classification to improve measurement of the impact of PN strategies and help focus resources.
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Affiliation(s)
- Claudia S Estcourt
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
- Sandyford Sexual Health Service, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Paul Flowers
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Jackie A Cassell
- Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, Brighton and Hove, UK
| | - Maria Pothoulaki
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Gabriele Vojt
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Fiona Mapp
- Institute for Global Health, University College London, London, UK
| | | | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - John Saunders
- Institute for Global Health, University College London, London, UK
- Blood Safety, Hepatitis, STI & HIV Division, Public Health England, London, UK
| | - Merle Symonds
- Department of Sexual Health, West Sussex Health and Social Care NHS Trust, Worthing, West Sussex, UK
| | - Alison Howarth
- Institute for Global Health, University College London, London, UK
| | | | - Rak Nandwani
- Sandyford Sexual Health Service, NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | - Alex Comer
- Central and North West London NHS Foundation Trust, London, UK
| | - Anne M Johnson
- Department of Infection & Population Health, University College London, London, UK
| | - Catherine H Mercer
- Centre for Sexual Health and HIV Research, University College London, London, UK
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Wayal S, Estcourt CS, Mercer CH, Saunders J, Low N, McKinnon T, Symonds M, Cassell JA. Optimising partner notification outcomes for bacterial sexually transmitted infections: a deliberative process and consensus, United Kingdom, 2019. Euro Surveill 2022; 27. [PMID: 35057899 PMCID: PMC8804665 DOI: 10.2807/1560-7917.es.2022.27.3.2001895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Partner notification (PN) is an essential element of sexually transmitted infection (STI) control. It enables identification, treatment and advice for sexual contacts who may benefit from additional preventive interventions such as HIV pre- and post-exposure prophylaxis. PN is most effective in reducing STI transmission when it reaches individuals who are most likely to have an STI and to engage in sexual behaviour that facilitates STI transmission, including having multiple and/or new sex partners. Outcomes of PN practice need to be measurable in order to inform standards. They need to address all five stages in the cascade of care: elicitation of partners, establishing contactable partners, notification, testing and treatment. In the United Kingdom, established outcome measures cover only the first three stages and do not take into account the type of sexual partnership. We report an evidence-based process to develop new PN outcomes and inform standards of care. We undertook a systematic literature review, evaluation of published information on types of sexual partnership and a modified Delphi process to reach consensus. We propose six new PN outcome measures at five stages of the cascade, including stratification by sex partnership type. Our framework for PN outcome measurement has potential to contribute in other domains, including Covid-19 contact tracing.
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Affiliation(s)
- Sonali Wayal
- Institute for Global Health, University College London, London, United Kingdom
| | - Claudia S Estcourt
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
| | - Catherine H Mercer
- Institute for Global Health, University College London, London, United Kingdom
| | - John Saunders
- Institute for Global Health, University College London, London, United Kingdom
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Tamsin McKinnon
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom
| | - Merle Symonds
- Western Sussex Hospitals NHS Foundation Trust, Worthing, West Sussex, United Kingdom
| | - Jackie A Cassell
- Brighton and Sussex Medical School, Falmer, East Sussex, United Kingdom
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Howarth AR, Estcourt CS, Ashcroft RE, Cassell JA. Building an Opt-Out Model for Service-Level Consent in the Context of New Data Regulations. Public Health Ethics 2022; 15:175-180. [DOI: 10.1093/phe/phab030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
The General Data Protection Regulation (GDPR) was introduced in 2018 to harmonize data privacy and security laws across the European Union (EU). It applies to any organization collecting personal data in the EU. To date, service-level consent has been used as a proportionate approach for clinical trials, which implement low-risk, routine, service-wide interventions for which individual consent is considered inappropriate. In the context of public health research, GDPR now requires that individuals have the option to choose whether their data may be used for research, which presents a challenge when consent has been given by the clinical service and not by individual service users. We report here on development of a pragmatic opt-out solution to this consent paradox in the context of a partner notification intervention trial in sexual health clinics in the UK. Our approach supports the individual’s right to withhold their data from trial analysis while routinely offering the same care to all patients.
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Suarez JD, Snackey Alvarez K, Anderson S, King H, Kirkpatrick E, Harms M, Martin R, Adhikari E. Decreasing Chlamydial Reinfections in a Female Urban Population. Sex Transm Dis 2021; 48:919-924. [PMID: 34117187 PMCID: PMC8594511 DOI: 10.1097/olq.0000000000001500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chlamydia is the most reported bacterial sexually transmitted infection (STI). The rates of chlamydia rose by 19% between 2011 and 2018. The STI National Strategic Plan (2021-2025), encourages coordinated solutions to address STIs and reduce disparities in disadvantaged populations. METHODS We implemented institutional policy changes, clinical decision support, including a Best Practice Advisory, and defaulted SmartSet with provider and patient education for women's health clinics at a large county health system. The advisory prompted providers to follow best practices when treating Chlamydia trachomatis infections. New C. trachomatis diagnosis cohorts were compared preintervention and postintervention for 6-month reinfection rates and patient and expedited partner treatment (EPT) practices. RESULTS Five hundred and nineteen women were included in the final analysis. Six-month chlamydia reinfection was lower in the postintervention cohort after adjusting for age (12.3% [26/211] vs 6.5% [20/308], P = 0.02). There was an increase in directly observed therapy of primary patients (17.5% [37/211] vs 77.3% [238/308], P < 0.001), an increase in EPT prescriptions written (4.3% [9/211] vs 79.5% [245/308], P < 0.0001), and a decrease of partners referred out for treatment (61.6% [130/211] vs 5.2% [16/308], P < 0.001) when compared with the control group. The majority of EPT was patient-delivered partner therapy postintervention (3.3% [7/211] vs 69.2% [213/308], P < 0.001). CONCLUSIONS A multifaceted, streamlined approach was effective in changing provider practices in the treatment of C. trachomatis. Increased rates of directly observed therapy for primary patient treatment and increased rates of patient-delivered partner therapy were observed postimplementation in addition to lower 6-month reinfection rates in a public women's health clinic setting.
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Affiliation(s)
| | - Kristin Snackey Alvarez
- Center for Innovation and Value, Parkland Health & Hospital System
- Division of Infectious Diseases, Department of Internal Medicine
| | | | - Helen King
- Division of Infectious Diseases, Department of Internal Medicine
| | | | - Michael Harms
- Center for Innovation and Value, Parkland Health & Hospital System
| | - Robert Martin
- Center for Innovation and Value, Parkland Health & Hospital System
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Emily Adhikari
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Shah M, Gishkori S, Edington M, King S, Winter AJ, Lockington D. Ten-year review of a shared care approach in the management of ocular chlamydia trachomatis infections. Eye (Lond) 2021; 35:1614-1619. [PMID: 32782336 PMCID: PMC8169935 DOI: 10.1038/s41433-020-01128-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/29/2020] [Accepted: 07/31/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Since 2007, the ocular 4:1 multiplex PCR assay in NHS Greater Glasgow and Clyde includes Chlamydia trachomatis (ocular chlamydia (OC)) testing. OC can be identified following routine 'viral' ophthalmic testing, including in asymptomatic patients. A published audit from 2008 identified only 25% of our OC patients attended and completed sexual health management, particularly when ophthalmologists initiated treatment. We subsequently created a shared care network between ophthalmology, virology and sexual health (including a designated sexual health advisor) to address these clinical issues. METHODS A 10-year retrospective service review audit from January 2010 to December 2019 was performed to evaluate this approach. RESULTS A total of 86 patients were identified (49 males (57%), median age 23 years (range 16-77)). Ophthalmologists initiated treatment for 37 patients (43%) prior to onward sexual health referral. Of this group, 5 (13.5%) received sub-optimal treatments, and 15 (40.5%) subsequently failed to attend sexual health services for partner notification. Of the 49 (57%) patients who attended sexual health, 25 (51%) had genital chlamydia co-infection, and 98% received adequate systemic treatment. All were offered full sexual health screening and 46 (93.9%) completed partner notification. CONCLUSIONS This shared care approach more than doubled the proportion of OC patients attending sexual health services over this 10-year period (previously 25%, now 57%). Ophthalmologists could defer treatment to sexual health for more effective OC management; however, challenges remain to address real-world issues of non-attendance, inadequate treatment and incomplete contact tracing. We recommend a multi-disciplinary approach to best manage OC cases identified following ophthalmic testing.
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Affiliation(s)
- Manaim Shah
- Tennent Institute of Ophthalmology, Glasgow, UK
| | | | | | - Samuel King
- Sandyford Sexual Health Services, Glasgow, UK
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8
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Middleton A, Pothoulaki M, Woode Owusu M, Flowers P, Mapp F, Vojt G, Laidlaw R, Estcourt CS. How can we make self-sampling packs for sexually transmitted infections and bloodborne viruses more inclusive? A qualitative study with people with mild learning disabilities and low health literacy. Sex Transm Infect 2021; 97:276-281. [PMID: 33906976 PMCID: PMC8165145 DOI: 10.1136/sextrans-2020-054869] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/15/2021] [Accepted: 03/12/2021] [Indexed: 11/20/2022] Open
Abstract
Objectives 1.5 million people in the UK have mild to moderate learning disabilities. STIs and bloodborne viruses (BBVs) are over-represented in people experiencing broader health inequalities, which include those with mild learning disabilities. Self-managed care, including self-sampling for STIs/BBVs, is increasingly commonplace, requiring agency and health literacy. To inform the development of a partner notification trial, we explored barriers and facilitators to correct use of an STI/BBV self-sampling pack among people with mild learning disabilities. Methods Using purposive and convenience sampling we conducted four interviews and five gender-specific focus groups with 25 people (13 women, 12 men) with mild learning disabilities (July–August 2018) in Scotland. We balanced deductive and inductive thematic analyses of audio transcripts to explore issues associated with barriers and facilitators to correct use of the pack. Results All participants found at least one element of the pack challenging or impossible, but welcomed the opportunity to undertake sexual health screening without attending a clinic and welcomed the inclusion of condoms. Reported barriers to correct use included perceived overly complex STI/BBV information and instructions, feeling overwhelmed and the manual dexterity required for blood sampling. Many women struggled interpreting anatomical diagrams depicting vulvovaginal self-swabbing. Facilitators included pre-existing STI/BBV knowledge, familiarity with self-management, good social support and knowing that the service afforded privacy. Conclusion In the first study to explore the usability of self-sampling packs for STI/BBV in people with learning disabilities, participants found it challenging to use the pack. Limiting information to the minimum required to inform decision-making, ‘easy read’ formats, simple language, large font sizes and simpler diagrams could improve acceptability. However, some people will remain unable to engage with self-sampling at all. To avoid widening health inequalities, face-to-face options should continue to be provided for those unable or unwilling to engage with self-managed care.
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Affiliation(s)
- Alan Middleton
- Nursing & Community Health, School of Health 7 ife Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Maria Pothoulaki
- Glasgow Caledonian University, School of Health and Life Sciences, Glasgow, UK
| | | | - Paul Flowers
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Fiona Mapp
- The Institute for Global Health, University College London, London, UK
| | - Gabriele Vojt
- Glasgow Caledonian University, School of Health and Life Sciences, Glasgow, UK
| | - Rebecca Laidlaw
- Nursing & Community Health, School of Health 7 ife Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Claudia S Estcourt
- Glasgow Caledonian University, School of Health and Life Sciences, Glasgow, UK
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Layton E, Goller JL, Coombe J, Temple-Smith M, Tomnay J, Vaisey A, Hocking JS. 'It's literally giving them a solution in their hands': the views of young Australians towards patient-delivered partner therapy for treating chlamydia. Sex Transm Infect 2021; 97:256-260. [PMID: 33441448 DOI: 10.1136/sextrans-2020-054820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/12/2020] [Accepted: 12/22/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Patient-delivered partner therapy (PDPT) is a method for providing antibiotic treatment for the sexual partners of an index patient with an STI by means of a prescription or medication that the index patient gives to their sexual partner(s). Qualitative research regarding barriers and enablers to PDPT has largely focused on the views of healthcare providers. In this study, we sought to investigate the views of young people (as potential health consumers) regarding PDPT for chlamydia. METHODS Semi-structured telephone interviews were conducted with young Australian men and women. Participants were asked to provide their views regarding PDPT from the perspective of both an index patient and partner. Purposive and snowball sampling was used. Data were analysed thematically. RESULTS We interviewed 22 people (13 women, 9 men) aged 18-30 years, 15 of whom had previously been tested for chlamydia. Despite none having previous knowledge of or experience using PDPT, all viewed it positively and thought it should be widely available. Participants reported that they would be willing to give PDPT to their sexual partners in situations where trust and comfort had been established, regardless of the relationship type. Protecting their partners' privacy was essential, with participants expressing reluctance to provide their partners' contact details to a doctor without consent. Beyond logistical benefits, PDPT was viewed as a facilitator to partner notification conversations by offering partners a potential solution. However, most interviewees indicated a preference to consult with a healthcare provider (GP or pharmacist) before taking PDPT medication. Participants indicated that legitimacy of information when navigating a chlamydia diagnosis was crucial and was preferably offered by healthcare providers. CONCLUSIONS Though PDPT is unlikely to fully replace partners' interactions with healthcare providers, it may facilitate partner notification conversations and provide partners greater choice on how, when and where they are treated.
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Affiliation(s)
- Elly Layton
- Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Jane L Goller
- Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Jacqueline Coombe
- Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Meredith Temple-Smith
- Department of General Practice, University of Melbourne, Carlton, Victoria, Australia
| | - Jane Tomnay
- Centre for Excellence in Rural Sexual Health, University of Melbourne, Shepparton, Victoria, Australia
| | - Alaina Vaisey
- Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Jane S Hocking
- Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
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Frackelton R, Jones K, Hamer B, Jones S, Hitchings E, Harrison J, Hughes-McGreal C, Clarke E. Managing contacts of chlamydia: should clinics implement a test and wait process? Int J STD AIDS 2020; 32:38-44. [PMID: 33121362 DOI: 10.1177/0956462420956852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
British guidelines recommend epidemiological treatment for all chlamydia contacts during the look back period. Some UK sexual health clinics follow a test and wait process for chlamydia contacts presenting after 14 days of exposure. The aim of this retrospective service evaluation was to determine the potential impact of implementing such a process for chlamydia contacts at our clinic. We reviewed the patient records of 548 chlamydia contacts over a 1-year period, and 588 patients with chlamydia over a 5-month period. Demographic and clinical characteristics data were collected.Chlamydia prevalence was 46% (254/548) in contacts, with prevalence varying by age (p=.008) and sexual risk (p=.04), but not by time since exposure (p=.29). For patients with chlamydia, there was a mean of 1.9 days between results notification and attending for treatment; a mean of 2.2 attempts were required to contact patients to return for treatment. Chlamydia prevalence in contacts is high. Not giving empirical treatment to contacts presenting after 14 days of exposure would result in 13.1% of the cohort needing to return for treatment. Patients found to have chlamydia returned promptly once informed of positive results.
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Affiliation(s)
| | - Kathy Jones
- Axess Sexual Health, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Beth Hamer
- Axess Sexual Health, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Sian Jones
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Elizabeth Hitchings
- Axess Sexual Health, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Joanne Harrison
- Axess Sexual Health, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Catherine Hughes-McGreal
- Axess Sexual Health, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Emily Clarke
- Axess Sexual Health, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
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