Effect of screening young men for Chlamydia trachomatis on the rates among women: a network modelling study for high-prevalence communities

The Risk of Pelvic Inflammatory Disease in Women Infected With Chlamydia (Chlamydia trachomatis): A Literature Review

A literature review was undertaken to examine the risk of developing pelvic inflammatory disease (PID) in women infected with Chlamydia trachomatis. A search of OVID Medline and Embase databases was conducted for studies published between 1946 and 26 June 2023. This review looked solely at prospective cohort study designs and searched reference lists of studies selected for inclusion. This literature review confirmed that C. trachomatisis a key factor in the development of PID in women through different pathogenic mechanisms. However, to reach more firm conclusions on the subject, further prospective cohort studies with a larger cohort size and a longer follow-up time are needed.

Evaluation of Chlamydia trachomatis screening from the perspective of health economics: a systematic review

Background

Most Chlamydia trachomatis (CT) infections are asymptomatic. The infection can persist and lead to severe sequelae. Therefore, screening for CT can primarily prevent serious sequelae.

Aim

To systematically evaluate CT screening from the perspective of health economics, summarize previous findings from different target populations, and make practical recommendations for developing local CT screening strategies.

Methods

PubMed, Web of Science, Embase, Cochran Library, and National Health Service Economic Evaluation Database (Ovid) were searched from January 1, 2000, to March 4, 2023. Studies reporting the cost-effectiveness, cost-benefit, or cost-utility of CT screening were eligible to be included. A narrative synthesis was used to analyze and report the results following the PRISMA guidelines. The Consensus on Health Economic Criteria (CHEC) list was used to assess the methodological quality of included studies.

Results

Our review finally comprised 39 studies addressing four populations: general sexually active people (n = 25), pregnant women (n = 4), women attending STD and abortion clinics (n = 4), and other high-risk individuals (n = 6). The total number of participants was ~7,991,198. The majority of studies assessed the cost-effectiveness or cost-utility of the screening method. The results showed that the following screening strategies may be cost-effective or cost-saving under certain conditions: performing CT screening in young people aged 15-24 in the general population, military recruits, and high school students; incorporating CT screening into routine antenatal care for pregnant women aged 15-30; opportunistic CT screening for women attending STD and abortion clinics; home-obtained sampling for CT screening using urine specimens or vaginal swab; performing CT screening for 14-30-year-old people who enter correctional institutions (i.e., jail, detention) as soon as possible; providing CT screening for female sex workers (FSWs) based on local incidence and prevalence; adding routine CT screening to HIV treatment using rectal samples from men who have sex with men (MSM).

Conclusion

We found that CT screening in general sexually active people aged 15-24, military recruits, high school students, pregnant women aged 15-30, women attending STD and abortion clinics, people entering jail, detention, FSWs, and MSM has health economic value. Due to the different prevalence of CT, diversities of economic conditions, and varying screening costs among different populations and different countries, regions, or settings, no uniform and standard screening strategies are currently available. Therefore, each country should consider its local condition and the results of health economic evaluations of CT screening programs in that country to develop appropriate CT screening strategies.

Estimating the test-adjusted incidence of Chlamydia trachomatis infections identified through Public Health Ontario Laboratories in Peel region, Ontario, 2010-2018: a population-based study

BACKGROUND

Public health guidelines for chlamydia testing are not sex specific, but young females test at a disproportionally higher rate than males and other age groups. This study aims to describe testing trends across age and sex subgroups, then estimate a test-adjusted incidence of chlamydia in these subgroups to identify gaps in current testing practices.

METHODS

We used a population-based study to examine observed chlamydia rates by age and sex subgroups: 15-19 years, 20-29 years, 30-39 years and older than 40 years. The study included diagnostic test results recorded by Public Health Ontario Laboratories between Jan. 1, 2010, and Dec. 31, 2018, for individuals living in Peel region, Ontario. We then employed meta-regression models as a method of standardization to estimate the effect of sex and age on standardized morbidity ratio, testing ratio and test positivity, then calculate a test-adjusted incidence of chlamydia for each subgroup.

RESULTS

Over the study period, infection, testing and test positivity varied across age and sex subgroups. Observed incidence and testing were highest in females aged 20-29 years, whereas males had the highest standardized test positivity across all age groups. After estimating test-adjusted incidence for each age-sex subgroup, males in the 15-19-year and 30-39-year age groups had an increase in incidence of 60.2% and 9.7%, respectively, compared with the observed incidence.

INTERPRETATION

We found that estimated test-adjusted incidence was higher than observed incidence in males aged 15-19 years and 30-39 years. This suggests that infections in males are likely being missed owing to differential testing, and this may be contributing to the persistent increase in reported cases in Canada. Public health programming that targets males, especially in high-risk settings and communities, and use of innovative partner notification methods could be critical to curbing overall rates of chlamydia.

Increasing incidence rates of sexually transmitted infections from 2010 to 2019: an analysis of temporal trends by geographical regions and age groups from the 2019 Global Burden of Disease Study

Background

World Health Organization announced its goal of ending sexually transmitted infection (STI) epidemics by 2030. To provide a reference for tailored prevention strategies, we analyzed trends and differences in STIs by geographical regions and age groups from 1990 to 2019.

Methods

Annual number of new infections and age-standardized incidence rates (ASRs) of syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes were recorded from the 2019 Global Burden of Disease study. We quantified the temporal trends of STIs by calculating changes in new infections and estimated annual percentage changes (EAPCs) of ASR.

Results

The ASRs of syphilis, chlamydia, trichomoniasis, and genital herpes increased by 1.70% (95% confidence interval [CI], 1.62–1.78%), 0.29% (95% CI 0.04–0.54%), 0.27% (95% CI 0.03–0.52%), and 0.40% (95% CI 0.36–0.44%) per year from 2010 to 2019 worldwide, respectively, while that of gonorrhea did not. The American regions had the greatest increase in ASR for syphilis (tropical Latin America: EAPC, 5.72; 95% CI 5.11–6.33), chlamydia (high-income North America: EAPC, 1.23; 95% CI 0.73–1.73), and gonorrhea (high-income North America: EAPC, 0.77; 95% CI 0.12–1.41). Additionally, southern sub-Saharan Africa and East Asia had the greatest increase in ASR for trichomoniasis (EAPC, 0.88; 95% CI 0.57–1.20) and genital herpes (EAPC, 1.44; 95% CI 0.83–2.06), respectively. In the most recent years, the population with the greatest incidence of syphilis tended to be younger globally (25–29 years in 2010 vs. 20–24 years in 2019) but older in North Africa and Middle East (20–24 year vs. 25–29 years); with chlamydia tended to be older in southern sub-Saharan Africa (25–29 years vs. 30–34 years) but younger in Australasia (40–44 years vs. 25–29 years); with genital herpes tended to be older in high-income North America (20–24 years vs. 25–29 years) and South Asia (25–29 years vs. 30–34 years).

Conclusions

Syphilis, chlamydia, trichomoniasis, and genital herpes showed a trend of increasing ASR from 2010 to 2019. The differences in trends by geographical regions and age groups point to the need for more targeted prevention strategies in key regions and populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07544-7.

Controversies and evidence on Chlamydia testing and treatment in asymptomatic women and men who have sex with men: a narrative review

Background

Chlamydia trachomatis (CT) is the most common bacterial sexually transmitted infection (STI) worldwide. CT is mainly asymptomatic. Test-and-treat strategies are widely implemented to prevent transmission and complications. Strategies are not without controversy in asymptomatic women and men who have sex with men (MSM). Concerns are emerging to test and treat asymptomatic persons for urogenital CT (‘Controversy 1’) and pharyngeal or rectal CT (‘Controversy 2’), whereby testing symptomatic persons is not under debate. Opposed views in CT treatment involve using azithromycin versus doxycycline (‘Controversy 3’). The objective of this review is to provide coverage of these public health and clinical controversies by reviewing the current scientific evidence.

Methods

A literature search was performed using PubMed for relevant publications between 2018 and September 2021, and iterative retrieval of additional relevant publications.

Results

Controversy 1. In women, the majority of asymptomatic CT are at the urogenital site, and detections mostly include viable CT. CT easily transmits to a partner and potentially also between the vaginal and rectal areas; the clinical impact of urogenital CT is established, although risks for adverse outcomes are uncertain. Wide-scale testing in asymptomatic women has not resulted in reduced prevalence. In MSM, evidence for the clinical impact of asymptomatic urogenital CT is lacking. Controversy 2. Rectal CT is common in women diagnosed with urogenital CT, but the clinical impact of asymptomatic rectal CT is uncertain. In MSM, rectal CT is common, and most CT infections are at the rectal site, yet the risk of longer term complications is unknown. In both sexes, pharyngeal CT is uncommon and has no documented clinical impact. Controversy 3. In the treatment of rectal CT, doxycycline has superior effectiveness to azithromycin. Evidence has also accumulated on the harms of test-and-treat strategies.

Conclusions

Current practices vary widely, from widescale test-and-treat approaches to more individual patient- and partner-level case management. Choosing which asymptomatic people to test at what anatomic site, and whether to test or not, requires an urgent (re-)definition of the goals of testing and treating asymptomatic persons. Treatment guidelines are shifting toward universal doxycycline use, and clinical practice now faces the challenge of implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07171-2.

Test-and-treat is a key strategy in the control of Chlamydia trachomatis (CT). We discuss recent controversies and present scientific evidence regarding urogenital, rectal, and pharyngeal CT test-and-treat strategies in women and in men who have sex with men (MSM). This should inform best practices for the prevention and management of the most common bacterial sexually transmitted infection (STI) worldwide.

Check It: A Community-Based Chlamydia Seek, Test, and Treat Program for Young Black Men Who Have Sex With Women in New Orleans, Louisiana

BACKGROUND

Check It is a novel, bundled, community-based seek, test, and treat Chlamydia trachomatis (Ct) screening program for 15- to 24-year-old Black men in New Orleans who have sex with women. The program design addressed barriers and facilitators to Ct screening/treatment by enlisting trusted community partners, incorporating participant input, providing free index/partner expedited treatment, developing relatable marketing materials and an educational Web site, encouraging peer referral, and providing a modest monetary incentive.

METHODS

Areas of high poverty were identified using census data; ethnographic/key informant interviews identified sites in those areas where the target population congregated. Black youth informed Web site design and social marketing. Content was inspirational/educational/amusing and endorsed recruitment and brand awareness. A community advisory board, participant interviews, community partner feedback, and recruitment staff involvement in the process evaluation helped refine the program in an ongoing manner.

RESULTS

During formative stages, 41 key informant/community advisory board members informed program refinement. Community partners provided venue locations (n = 65) and participant referrals. Between May 22, 2017, and February 28, 2020, 1890 men were enrolled (acceptance rate, 96.0%) with Ct infection rate of 10.2%. Overall study treatment was provided to 86.1% (71.4%-90.9%) of participants who tested positive and 28.5% (14.5%-41.5%) of their partners. Findings from in-depth interviews with participants (n = 43) led to increased treatment uptake.

CONCLUSIONS

C. trachomatis community screening of young Black men was successful through collaboration with trusted community partners, by tailoring implements/marketing with participant input, reducing barriers to treatment, and providing modest monetary incentives. The Check It program can serve as a roadmap for reducing health disparities in this population.

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.

Changes in Sexual Behavior Related to the COVID-19 Stay-at-Home Orders Among Young Black Men Who Have Sex With Women in New Orleans, LA

BACKGROUND

COVID-19 stay-at-home orders enacted in New Orleans, LA on March 16, 2020, may have caused changes in the way young men interacted with sex partners.

METHODS

An online substudy was conducted (May 21, 2020 to June 9, 2020) among Black men who have sex with women, 18 years and older, and who had previously enrolled in the parent study Check It (May 17, 2017 to March 6, 2020) to assess changes in sexual behavior during the stay-at-home orders.

RESULTS

Among 111 participants, from enrollment in Check It to during stay-at-home orders, recent vaginal sex declined from 96.4% to 47.8% (P < 0.0001), reports of multiple female sex partners declined from 45.0% to 14.4% (P < 0.0001), and sexual abstinence increased from 3.6% to 38.7% (P < 0.0001). Among those who did have vaginal sex, condomless sex rates did not change between enrollment in Check It and the substudy (64.5% vs 67.9%, P = 0.68). During stay-at-home orders oral sex, virtual sex, and pornography viewing were 40.5%, 42.3%, and 76.6%, respectively. Some (17.1%) acquired a new sex partner during stay-at-home orders, and 44.1% left their home to meet a partner for sex. Only 27.9% had seen information about safe sex during the pandemic. Income was diminished for 62.2% and 23.4% moved away from New Orleans when stay-at-home orders were enacted.

CONCLUSIONS

Although there was an overall reduction in physical sex, half of participants reported physical sex, with many leaving their home to have sex during stay-at-home orders and many not using condoms. Others adopted sexual abstinence, increased virtual sex, and/or pornography viewing, which may have protected them from both sexually transmitted infections and COVID-19.