A national evaluation using standardised patient actors to assess STI services in public sector clinical sentinel surveillance facilities in South Africa

Factors associated with partner notification intentions among symptomatic sexually transmitted infection service attendees in South Africa

BACKGROUND

In South Africa (SA), a client-initiated partner notification (PN) approach is implemented for the management of sexual partners of patients presenting with sexually transmitted infections (STIs) or STI syndromes.

OBJECTIVES

To explore the demographic, sexual behavioural and clinical characteristics associated with PN intentions among symptomatic STI service attendees at sentinel primary healthcare facilities in three SA provinces.

METHODS

We analysed cross-sectional data obtained from 1 293 adults enrolled into STI aetiological surveillance during 2019 - 2020 in Gauteng, KwaZulu-Natal and Western Cape provinces. Self-reported sexual practices, PN intentions and clinical data were collected using nurse-administrated questionnaires. We assessed gender-stratified factors associated with the index case's willingness to notify their sexual partners of their STI syndrome diagnosis. Univariable and multivariable Poisson regression models with robust error variance were used to determine factors associated with gender-stratified PN intentions.

RESULTS

The enrolled participants comprised 887 male (68.6%) and 406 female (31.4%) STI clients. Self-reported PN intentions were higher among women than men (83.5% v. 64.4%; p<0.001). Multivariable analyses revealed that casual sex partnerships during the preceding 3-month period and enrolment at the KwaZulu-Natal site were independent barriers to PN intent among male participants. For females, enrolment at the Gauteng site was independently associated with lower PN intentions, while presenting with genital ulcer syndrome was a motivator towards PN intent. The primary reasons cited for non-disclosure across both genders were casual sexual encounters, followed by geographically distant partnerships and fear of disclosure.

CONCLUSION

We show that demographic and behavioural characteristics, as well as relationship dynamics, may influence the PN intentions of STI service attendees in SA. Alternative PN strategies should be considered, based on the reported barriers, to increase overall STI notification, strengthen partner management and ultimately reduce STI incidence.

Improving Quality of PrEP Counseling for Adolescent Girls and Young Women in Kenya With Standardized Patient Actors: A Dose-Response Analysis

BACKGROUND

Health care worker (HCW) training using standardized patient actors (SPs) is an evidence-based approach for improving patient-provider interactions. We evaluated whether SP training among HCWs in Western Kenya improved the quality of pre-exposure prophylaxis (PrEP) counseling for adolescent girls and young women (AGYW).

METHODS

We conducted a 2-day SP training intervention among HCWs providing PrEP counseling for AGYW. Six trained SPs role played one encounter each with HCWs following scripts depicting common PrEP-seeking scenarios. SPs used checklists to report and discuss domains of adherence to national PrEP guidelines, communication, and interpersonal skills using validated scales after each encounter. HCWs presented to each case in a random order. Overall and domain-specific mean score percentages were compared between the first and subsequent case encounters using generalized linear models, clustering by HCWs.

RESULTS

During 564 training cases among 94 HCWs, the overall mean quality of PrEP counseling score was 83.1 (SD: 10.1); scores improved over the course of the 6 encounters (P < 0.001). Compared with the first case encounter, the mean scores for the fourth were significantly higher (79.1 vs. 85.9, P < 0.001). The mean scores plateaued from the fourth to the sixth case (85.2). Although HCWs demonstrated high baseline communication (95.3) and interpersonal skills (83.7), adherence to PrEP guidelines at baseline was suboptimal (57.6). By the fourth case, scores increased significantly (P < 0.001) for all domains.

CONCLUSIONS

SP training improved PrEP counseling overall and in domains of interpersonal skills, use of guidelines, and communication with AGYW and could be useful in efforts to improve the quality of PrEP counseling for AGYW.

Predicting Sexually Transmitted Infections Among HIV+ Adolescents and Young Adults: A Novel Risk Score to Augment Syndromic Management in Eswatini

BACKGROUND

Despite poor predictive power, syndromic screening is standard of care for diagnosing sexually transmitted infections (STIs) in low-resource, high HIV-burden settings. Predictive models may augment syndromic screening when diagnostic testing is not universally available for screening high-risk patient populations such as adolescents and young adults living with HIV.

SETTING

Four hundred fifteen adolescents and young adults living with HIV, age 15-24 years, participated from 3 clinical sites in Eswatini, provided urine, sexual and medical history, and completed physical examination.

METHODS

STI cases were defined by a positive Xpert result for Chlamydia trachomatis, Neisseria gonorrhea, or Trichomonas vaginalis. Features predictive of an STI were selected through Least Absolute Shrinkage and Selection Operator (LASSO) with 5-fold cross validation. Various model strategies were compared with parametric area under the Receiver Operator Curve (AUC) estimation and inferences were made with bootstrapped standard errors.

RESULTS

Syndromic screening poorly predicted STIs [AUC 0.640 95% Confidence Interval (95% CI): 0.577 to 0.703]. A model considering 5 predictors (age group, sex, any sexual activity, not always using condoms (either self or partner), a partner who was 25 years or older, and horizontal or unknown mode of HIV acquisition) predicted STIs better than syndromic screening [AUC: 0.829 (95% CI: 0.774 to 0.885)] and was improved when the risk score was supplemented with leukocyte esterase (LE) testing [AUC: 0.883 (95% CI: 0.806 to 0.961)].

CONCLUSIONS

This simple predictive model, with or without leukocyte esterase testing, could improve STI diagnosis in HIV-positive adolescents and young adults in high burden settings through complementary use with syndromic screening and to guide patient selection for molecular STI diagnostic tests.

Risky sexual behaviour amidst predicament of acceptable sexually transmitted infection partner notification modalities: A cross-sectional survey amongst minibus taxi drivers in Gauteng Province, South Africa

Background

Sexually transmitted infection patient-initiated partner notification (PN) approach has been implemented over a decade in South Africa, however, use and update by patients has been limited. This study assessed the perceived use of patient-initiated PN by using referral slips and measured the level of acceptability of provider-initiated PN by using short message service (SMS) to the personal mobile phones of sexual partners.

Methods

A formative evaluation approach using a quantitative survey amongst 722 minibus taxi drivers in nine major taxi ranks in Tshwane Municipality, Gauteng Province. STATA IC version 13 was used for data analyses.

Results

The mean age of the participants was 37.2 years (59%) were single, 59.5% had multiple sexual partners, 52.2% did not use a condom during the last sexual act, 42.8% reported inconsistent use of condoms and 65% tested for HIV in the past 12 months. The majority (98.2%) understood the importance of PN, but 51% would prefer telling a sexual partner face to face. Perceived easiness of delivering a PN slip was 69.1%, and 93% would use a PN slip received from a partner. Acceptability of provider-initiated PN by using an SMS was 62.7% and about a third (32.5%) were not in favour of provider-initiated PN by SMS. Twenty four point 7 percent (24.7%) preferred patient-initiated PN and 24.3% preferred provider-initiated PN.

Conclusion

Preferred patient-initiated and provider-initiated PN was almost equal, hence, the provider-initiated PN should be augmented to support the current patient-initiated PN to increase the overall STI notification.

Standardised patient encounters to improve quality of counselling for pre-exposure prophylaxis (PrEP) in adolescent girls and young women (AGYW) in Kenya: study protocol of a cluster randomised controlled trial

INTRODUCTION

Adolescent girls and young women (AGYW) in sub-Saharan Africa are at high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP) demonstration projects observe that AGYW uptake and adherence to PrEP during risk periods is suboptimal. Judgemental interactions with healthcare workers (HCW) and inadequate counselling can be barriers to PrEP use among AGYW. Improving HCW competency and communication to support PrEP delivery to AGYW requires new strategies.

METHODS AND ANALYSIS

PrEP Implementation for Young Women and Adolescents Program-standardised patient (PrIYA-SP) is a cluster randomised trial of a standardised patient actor (SP) training intervention designed to improve HCW adherence to PrEP guidelines and communication skills. We purposively selected 24 clinics offering PrEP services under fully programmatic conditions in Kisumu County, Kenya. At baseline, unannounced SP 'mystery shoppers' present to clinics portraying AGYW in common PrEP scenarios for a cross-sectional assessment of PrEP delivery. Twelve facilities will be randomised to receive a 2-day training intervention, consisting of lectures, role-playing with SPs and group debriefing. Unannounced SPs will repeat the assessment in all 24 sites following the intervention. The primary outcome is quality of PrEP counselling, including adherence to national guidelines and communication skills, scored on a checklist by SPs blinded to intervention assignment. An intention-to-treat (ITT) analysis will evaluate whether the intervention resulted in higher scores within intervention compared with control facilities, adjusted for baseline SP scores and accounting for clustering by facility. We hypothesise that the intervention will improve quality of PrEP counselling compared with standard of care. Results from this study will inform guidelines for PrEP delivery to AGYW in low-resource settings and offer a potentially scalable strategy to improve service delivery for this high-risk group.

ETHICS AND DISSEMINATION

The protocol was approved by institutional review boards at Kenyatta National Hospital and University of Washington. An external advisory committee monitors social harms. Results will be disseminated through peer-reviewed journals and presentations.

TRIAL REGISTRATION NUMBER

NCT03875950.

Medical Male Circumcision and Associations Among Sexually Transmitted Infections Service Attendees

Medical male circumcision (MMC) is a proven intervention for preventing HIV acquisition among males. We describe the circumcision status, eligibility for MMC referral and associations with HIV positivity among symptomatic males attending sexually transmitted infections (STI) services. This study was a secondary analysis of cross-sectional data collected during sentinel surveillance for STI aetiologies. In the sentinel surveillance conducted at primary care facilities located in six South African provinces, an anonymous questionnaire was administered followed by collection of appropriate genital and blood specimens for laboratory testing including HIV, rapid plasma reagin (RPR) and HSV-2 serological testing. During analysis, multivariable logistic regression was used to determine association between prevalent HIV infection and male circumcision among males who were HSV-2 AND/OR RPR serology positive and among those who were negative. A total of 847 males were included the analysis, among whom the median age was 28 years (IQR 24-32 years) with 26.3% aged < 25 years. Of these, 166 (19.6%) were medically circumcised, 350 (41.4%) traditionally circumcised while 324 (39%) were not circumcised. The yield of assessment for MMC referral was 27.7%. Overall HIV positivity was 23.1%. Compared to no circumcision, MMC had a statistically insignificant 62% lower odds of being HIV positive -among males who were HSV-2 and RPR negative- adjusted odds ratio [aOR] 0.38 [95% confidence interval (CI) 0.12-1.18], p = 0.094. Among those HSV-2 AND/OR RPR positive, MMC had a statistically insignificant 26% lower odds of being HIV positive- aOR 0.74 (95% CI 0.41-1.36), p = 0.334. In both groups HIV positivity increased with age but was positively associated with condom use at last sexual encounter [aOR 3.41 (95% CI 1.43-8.15)] and previous treatment for an STI syndrome [aOR 3.81 (95% CI 1.60-9.05)] among those HSV-2 and RPR negative. High HIV positivity and high yield of eligibility for VMMC referral among males attending STI services points to the need for better integration of HIV prevention and treatment with STI care.

Provision of Sexually Transmitted Infection Services in a Mobile Clinic Reveals High Unmet Need in Remote Areas of South Africa: A Cross-sectional Study

BACKGROUND

The burden of sexually transmitted infections (STIs) in areas of sub-Saharan Africa with poor access to health care services is not well documented. In remote areas of South Africa, we investigated the prevalence of STIs and approaches to providing STI services through a mobile clinic.

METHODS

We recruited 251 adult women visiting a mobile clinic that normally provides general health education and screening services, but not STI care. Clinical and sexual history was obtained and vaginal specimens were tested for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium infection and for Candida albicans and bacterial vaginosis.

RESULTS

Laboratory test was positive for 133 (53%) of 251 women for at least 1 STI: C. trachomatis was observed in 52 (21%) women, N. gonorrhoeae in 39 (16%) women, T. vaginalis in 81 (32%) women and M. genitalium in 21 (8%) women. Eighty-one (32%) women met the criteria for vaginal discharge syndrome, of which 58% (47/81) would have been treated accurately. Among asymptomatic women 84 (49%) of 170 were diagnosed with an STI but untreated under the syndromic approach. We could not identify factors associated with asymptomatic STI infection.

CONCLUSIONS

There is a high unmet need for STI care in rural South African settings with poor access to health care services. Provision of STI services in a mobile clinic using the syndromic management approach provides a useful approach, but would have to be enhanced by targeted diagnostics to successfully address the burden of infection.

Training Exposure and Self-Rated Competence among HIV Care Providers Working with Adolescents in Kenya

Lack of health care worker (HCW) training is a barrier to implementing youth-friendly services. We examined training coverage and self-reported competence, defined as knowledge, abilities, and attitudes, of HCWs caring for adolescents living with HIV (ALWH) in Kenya. Surveys were conducted with 24 managers and 142 HCWs. Competence measures were guided by expert input and Kalamazoo II Consensus items. Health care workers had a median of 3 (interquartile range [IQR]: 1-6) years of experience working with ALWH, and 40.1% reported exposure to any ALWH training. Median overall competence was 78.1% (IQR: 68.8-84.4). In multivariable linear regression analyses, more years caring for ALWH and any prior training in adolescent HIV care were associated with significantly higher self-rated competence. Training coverage for adolescent HIV care remains suboptimal. Targeting HCWs with less work experience and training exposure may be a useful and efficient approach to improve quality of youth-friendly HIV services.

Evaluation of Timeliness, Simplicity, Acceptability, and Flexibility in Child Mortality Surveillance System for Children Aged 1-59 Months in Iran

Background:

Child mortality surveillance system (CMSS) for children aged 1–59 months is a critical issue in the prevention of mortality. This surveillance system like other health programs needs to be evaluated. Therefore, this study aims to evaluate CMSS in Iran.

Methods:

This evaluation was performed from March 2015 to March 2016 based on selected criteria for assessing the public health surveillance system proposed by the Centers for Disease Control and Prevention. Selected criteria examined in this study included timeliness, simplicity, acceptability, and flexibility. These criteria were evaluated in two ways. First, it included the use of a researcher-made questionnaire. The questionnaires were completed by 100 experts on CMSS. Second, to perform a more exact evaluation of these criteria, 24 of these experts were selected for the focus group.

Results:

In this study, the response rate was 91% (42% hospital-based and 49% primary care-based). In the timeliness section, 49% of the experts believed that approvals of the child mortality committees have not been sent within the designated time frame; hardware, software, and questionnaires were reported as effective factors in this respect. The structural and administrative problems were effective in simplicity domain and the experts of mortality registration and mood of relatives were effective in acceptability domain. The flexibility of the system was high and appropriate.

Conclusions:

The findings of the present study reveal that CMSS has some limitations and problems in the timeliness, simplicity, and acceptability criteria, which can be resolved. But this program has an appropriate situation in terms of flexibility.

How to do (or not to do) … using the standardized patient method to measure clinical quality of care in LMIC health facilities

Standardized patients (SPs), i.e. mystery shoppers for healthcare providers, are increasingly used as a tool to measure quality of clinical care, particularly in low- and middle-income countries where medical record abstraction is unlikely to be feasible. The SP method allows care to be observed without the provider's knowledge, removing concerns about the Hawthorne effect, and means that providers can be directly compared against each other. However, their undercover nature means that there are methodological and ethical challenges beyond those found in normal fieldwork. We draw on a systematic review and our own experience of implementing such studies to discuss six key steps in designing and executing SP studies in healthcare facilities, which are more complex than those in retail settings. Researchers must carefully choose the symptoms or conditions the SPs will present in order to minimize potential harm to fieldworkers, reduce the risk of detection and ensure that there is a meaningful measure of clinical care. They must carefully define the types of outcomes to be documented, develop the study scripts and questionnaires, and adopt an appropriate sampling strategy. Particular attention is required to ethical considerations and to assessing detection by providers. Such studies require thorough planning, piloting and training, and a dedicated and engaged field team. With sufficient effort, SP studies can provide uniquely rich data, giving insights into how care is provided which is of great value to both researchers and policymakers.

An Integrated Care Model With Implementation Roadmap to Improve Chlamydia trachomatis Management and Control in India

Chlamydia trachomatis is the world's most prevalent bacterial Sexually Transmitted infection (STI). It is associated with a wide range of health consequences and sequelae in both the short and long term. Enhanced control of urogenital C. trachomatis infection is particularly important in low- and middle-income countries such as India, where most of the burden goes unnoticed and where limited systematic data is available to gauge the current situation. The World Health Organization (WHO) recently issued its latest strategy on STIs, which is aligned with the achievement of the Sustainable Development Goals (SDGs). Taking the WHO framework into account; this paper puts forward an integrated care model to strengthen the management and control of C. trachomatis in India. The model is compiled of five key components of STI management (awareness, prevention diagnosis, treatment and follow-up). The model considers barriers to effective C. trachomatis control into account. The barriers are discussed and compiled into different categories. A roadmap for the implementation of other similar models to enhance C. trachomatis control in the future is provided.

Acceptability and efficacy of partner notification for curable sexually transmitted infections in sub-Saharan Africa: A systematic review

Comprehensive case management of sexually transmitted infections (STIs) includes partner notification. We reviewed the recent literature evaluating the acceptability and efficacy of partner notification strategies (i.e. direct patient referral, provider referral, or expedited partner treatment) for curable STIs in sub-Saharan Africa. We conducted a systematic search following PRISMA guidelines: published January 2008 to June 2017 in the English language, study in sub-Saharan Africa, and discussion of any curable STI with an outcome on partner notification. We searched six electronic databases, conference abstracts, online clinical trial registries, and article bibliographies. The results showed that out of the 74 identified articles, 55 did not meet inclusion criteria. Of the 11 studies evaluating direct patient referral, the proportion of index cases ( n = 4163) who successfully notified sex partner(s) was 53% (range 23-95%). Among those who notified ( n = 1727), 25% (range 0-77%) had partner(s) that sought evaluation (95% CI 0.51-0.54; 95% CI 0.23-0.27). Both provider referral and expedited partner treatment had higher proportions of partner(s) who sought treatment ( n = 208, 69% and n = 44, 84%, respectively). Direct patient referral is the most commonly used and evaluated partner notification strategy for STIs in sub-Saharan Africa with mixed success. We recommend future research to investigate other strategies such as expedited partner treatment.

Adult gonorrhea, chlamydia and syphilis prevalence, incidence, treatment and syndromic case reporting in South Africa: Estimates using the Spectrum-STI model, 1990-2017

OBJECTIVES

To estimate trends in prevalence and incidence of syphilis, gonorrhea and chlamydia in adult men and women in South Africa.

METHODS

The Spectrum-STI tool estimated trends in prevalence and incidence of active syphilis, gonorrhea and chlamydia, fitting South African prevalence data. Results were used, alongside programmatic surveillance data, to estimate trends in incident gonorrhea cases resistant to first-line treatment, and the reporting gap of symptomatic male gonorrhea and chlamydia cases treated but not reported as cases of urethritis syndrome.

RESULTS

In 2017 adult (15-49 years) the estimated female and male prevalences for syphilis were 0.50% (95% CI: 0.32-0.80%) and 0.97% (0.19-2.28%), for gonorrhea 6.6% (3.8-10.8%) and 3.5% (1.7-6.1%), and for chlamydia 14.7% (9.9-21%) and 6.0% (3.8-10.4%), respectively. Between 1990 and 2017 the estimated prevalence of syphilis declined steadily in women and men, probably in part reflecting improved treatment coverage. For gonorrhea and chlamydia, estimated prevalence and incidence showed no consistent time trend in either women or men. Despite growing annual numbers of gonorrhea cases - reflecting population growth - the estimated number of first line treatment-resistant gonorrhea cases did not increase between 2008 and 2017, owing to changes in first-line antimicrobial treatment regimens for gonorrhea in 2008 and 2014/5. Case reporting completeness among treated male urethritis syndrome episodes was estimated at 10-28% in 2017.

CONCLUSION

South Africa continues to suffer a high STI burden. Improvements in access and quality of maternal, STI and HIV health care services likely contributed to the decline in syphilis prevalence. The lack of any decline in gonorrhea and chlamydia prevalence highlights the need to enhance STI services beyond clinic-based syndromic case management, to reinvigorate primary STI and HIV prevention and, especially for women, to screen for asymptomatic infections.

Knowledge of HIV status and antiretroviral therapy use among sexually transmitted infections service attendees and the case for improving the integration of services in South Africa: A cross sectional study

We describe knowledge of human immunodeficiency virus (HIV) status, correct report of HIV status and antiretroviral therapy (ART) use among sexually transmitted infection (STI) service attendees in South Africa.An anonymous questionnaire was administered and serological HIV testing done. Proportions of attendees reporting knowledge of HIV status and HIV status consistent with laboratory results and ART use (among HIV positives) were determined as were factors associated with knowledge and inconsistent report of HIV status.Of 1054 attendees, 288 (27.3%) were HIV positive and 830 (78.8%) self-reported knowledge of HIV status. Not knowing one's HIV status was associated with male gender [adjusted Odds Ratio (aOR) 2.66 (95% confidence interval (CI) 1.70-4.18] medical circumcision [aOR 0.48 (95% CI 0.24-0.95)] and site [Gauteng Province (GP)-aOR 6.20 (95% CI 3.51-10.95), Eastern Cape (EC)-aOR 17.29 (95% CI 10.08- 29.66) versus Free State (FS)/Western Cape (WC) sites]. Of 219 HIV positive attendees with knowledge of HIV status, 136 (62.1%) self-reported being HIV positive, of whom 80 (58.8%) reported taking ARVs in the preceding 3 days. Inconsistent report of status was associated with males [aOR 2.26 (95%CI 1.05-4.87)], prior STI treatment [aOR 0.33 (95% CI 0.16-0.69)], recent HIV testing (6months) [aOR 3.20 (95% CI 1.62-6.36)] and site [GP-aOR 6.89 (95% 3.21-14.82), EC-aOR 5.08 (95% CI 2.15-11.64) versus FS/WC sites]. Knowledge of HIV status was lower than targeted. HIV testing and linkage to care services are essential in STI-related care and validation of self-reported indicators in this population maybe necessary.

Simulated patient encounters to improve adolescent retention in HIV care in Kenya: study protocol of a stepped-wedge randomized controlled trial

Background

Adolescent-friendly policies aim to tailor HIV services for adolescents and young adults aged 10–24 years (AYA) to promote health outcomes and improve retention in HIV care and treatment. However, few interventions focus on improving healthcare worker (HCW) competencies and skills for provision of high-quality adolescent care. Standardized patients (SPs) are trained actors who work with HCWs in mock clinical encounters to improve clinical assessment, communication, and empathy skills. This stepped-wedge randomized controlled trial will evaluate a clinical training intervention utilizing SPs to improve HCW skills in caring for HIV-positive AYA, resulting in increased retention in care.

Methods/design

The trial will utilize a stepped-wedge design to evaluate a training intervention using SPs to train HCWs in assessment, communication, and empathy skills for AYA HIV care. We will recruit 24 clinics in Kenya with an active electronic medical record (EMR) system and at least 40 adolescents enrolled in HIV care per site. Stratified randomization by county will be used to assign clinics to one of four waves – time periods when they receive the intervention – with each wave including six clinics. From each clinic, up to 10 HCWs will participate in the training intervention. SP training includes didactic sessions in adolescent health, current guidelines, communication skills, and motivational interviewing techniques. HCW participants will rotate through seven standardized SP scenarios, followed by SP feedback, group debriefing, and remote expert evaluation. AYA outcomes will be assessed using routine clinic data. The primary outcome is AYA retention in HIV care, defined as returning for first follow-up visit within 6 months of presenting to care, or returning for a first follow-up visit after re-engagement in care in AYA with a previous history of being lost to follow-up. Secondary outcomes include HCW competency scores, AYA satisfaction with care, and AYA clinical outcomes including CD4 and viral load. Additional analyses will determine cost-effectiveness of the intervention.

Discussion

This trial will contribute valuable information to HIV programs in Kenya and other low-resource settings, providing a potentially scalable strategy to improve quality of care and retention in critical HIV services in this population.

Trial registration

ClinicalTrials.gov, ID: NCT02928900. Registered 26 August 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2266-z) contains supplementary material, which is available to authorized users.