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Kersaudy-Rahib D, Lydié N, Leroy C, March L, Bébéar C, Arwidson P, de Barbeyrac B. Chlamyweb Study II: a randomised controlled trial (RCT) of an online offer of home-based Chlamydia trachomatis sampling in France. Sex Transm Infect 2017; 93:188-195. [PMID: 28377422 DOI: 10.1136/sextrans-2015-052510] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 05/20/2016] [Accepted: 05/28/2016] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The number of cases of Chlamydia trachomatis (Ct) diagnosed has increased in the past 15 years in France as well as in other European countries. This paper reports a randomised controlled trial (RCT) to evaluate whether the offer of home-based testing over the internet increased the number of young people tested for chlamydia compared with the current testing strategy and to estimate the number and risks factors of the infected population. This RCT took place as an element of the Chlamyweb Study-a study aiming to evaluate an intervention (the Chlamyweb Intervention) involving the offer of a free self-sampling kit online to sexually active men and women aged 18-24 years in France. METHODS Participants in the Chlamyweb RCT (n=11 075) received either an offer of a free self-sampling kit (intervention group) or were invited to be screened in primary care settings (control group). Risks ratios were used to compare screening rates between the intervention and control groups. Risk factors were analysed for infected people in the intervention group. RESULTS The screening frequency was about three times higher among young people who received a self-sampling kit than those who only received a tailored recommendation to be screened (29.2% vs 8.7%). Although rates of screening among men were lower than among women (23.9% vs 33.9%), the intervention effect was greater among men (adjusted risk ratios (aRR)=4.55 vs aRR=2.94). Ct positivity (6.8%) was similar to that observed in STI clinics. It was higher in women (8.3%) than in men (4.4%). CONCLUSIONS These results invite us to consider the establishment of a large home-based screening programme, although additional studies including economic assessments are needed to evaluate the most appropriate combination of strategies in the French context. TRIAL REGISTRAION NUMBER AFFSAPS n° IDRCB 0211-A01000-41; Results.
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Affiliation(s)
| | - Nathalie Lydié
- Sexual Health Unit, Santé publique France, Saint-Maurice, France
| | - Chloé Leroy
- Univ. Bordeaux and INRA, USC EA 3671 Mycoplasmal and Chlamydial Infections in Humans, French National Reference Centre (NRC) for Chlamydial Infections, Bordeaux, France
| | - Laura March
- Sexual Health Unit, Santé publique France, Saint-Maurice, France
| | - Cécile Bébéar
- Univ. Bordeaux and INRA, USC EA 3671 Mycoplasmal and Chlamydial Infections in Humans, French National Reference Centre (NRC) for Chlamydial Infections, Bordeaux, France
| | - Pierre Arwidson
- Sexual Health Unit, Santé publique France, Saint-Maurice, France
| | - Bertille de Barbeyrac
- Univ. Bordeaux and INRA, USC EA 3671 Mycoplasmal and Chlamydial Infections in Humans, French National Reference Centre (NRC) for Chlamydial Infections, Bordeaux, France
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Estcourt C, Sutcliffe L, Mercer CH, Copas A, Saunders J, Roberts TE, Fuller SS, Jackson LJ, Sutton AJ, White PJ, Birger R, Rait G, Johnson A, Hart G, Muniina P, Cassell J. The Ballseye programme: a mixed-methods programme of research in traditional sexual health and alternative community settings to improve the sexual health of men in the UK. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04200] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundSexually transmitted infection (STI) diagnoses are increasing and efforts to reduce transmission have failed. There are major uncertainties in the evidence base surrounding the delivery of STI care for men.AimTo improve the sexual health of young men in the UK by determining optimal strategies for STI testing and careObjectivesTo develop an evidence-based clinical algorithm for STI testing in asymptomatic men; model mathematically the epidemiological and economic impact of removing microscopy from routine STI testing in asymptomatic men; conduct a pilot randomised controlled trial (RCT) of accelerated partner therapy (APT; new models of partner notification to rapidly treat male sex partners of people with STIs) in primary care; explore the acceptability of diverse venues for STI screening in men; and determine optimal models for the delivery of screening.DesignSystematic review of the clinical consequences of asymptomatic non-chlamydial, non-gonococcal urethritis (NCNGU); case–control study of factors associated with NCNGU; mathematical modelling of the epidemiological and economic impact of removing microscopy from asymptomatic screening and cost-effectiveness analysis; pilot RCT of APT for male sex partners of women diagnosed withChlamydia trachomatisinfection in primary care; stratified random probability sample survey of UK young men; qualitative study of men’s views on accessing STI testing; SPORTSMART pilot cluster RCT of two STI screening interventions in amateur football clubs; and anonymous questionnaire survey of STI risk and previous testing behaviour in men in football clubs.SettingsGeneral population, genitourinary medicine clinic attenders, general practice and community contraception and sexual health clinic attenders and amateur football clubs.ParticipantsMen and women.InterventionsPartner notification interventions: APTHotline [telephone assessment of partner(s)] and APTPharmacy [community pharmacist assessment of partner(s)]. SPORTSMART interventions: football captain-led and health adviser-led promotion of urine-based STI screening.Main outcome measuresFor the APT pilot RCT, the primary outcome, determined for each contactable partner, was whether or not they were considered to have been treated within 6 weeks of index diagnosis. For the SPORTSMART pilot RCT, the primary outcome was the proportion of eligible men accepting screening.ResultsNon-chlamydial, non-gonococcal urethritis is not associated with significant clinical consequences for men or their sexual partners but study quality is poor (systematic review). Men with symptomatic and asymptomatic NCNGU and healthy men share similar demographic, behavioural and clinical variables (case–control study). Removal of urethral microscopy from routine asymptomatic screening is likely to lead to a small rise in pelvic inflammatory disease (PID) but could save > £5M over 20 years (mathematical modelling and health economics analysis). In the APT pilot RCT the proportion of partners treated by the APTHotline [39/111 (35%)], APTPharmacy [46/100 (46%)] and standard patient referral [46/102 (45%)] did not meet national standards but exceeded previously reported outcomes in community settings. Men’s reported willingness to access self-sampling kits for STIs and human immunodeficiency virus infection was high. Traditional health-care settings were preferred but sports venues were acceptable to half of men who played sport (random probability sample survey). Men appear to prefer a ‘straightforward’ approach to STI screening, accessible as part of their daily activities (qualitative study). Uptake of STI screening in the SPORTSMART RCT was high, irrespective of arm [captain led 28/56 (50%); health-care professional led 31/46 (67%); poster only 31/51 (61%)], and costs were similar. Men were at risk of STIs but previous testing was common.ConclusionsMen find traditional health-care settings the most acceptable places to access STI screening. Self-sampling kits in football clubs could widen access to screening and offer a public health impact for men with limited local sexual health services. Available evidence does not support an association between asymptomatic NCNGU and significant adverse clinical outcomes for men or their sexual partners but the literature is of poor quality. Similarities in characteristics of men with and without NCNGU precluded development of a meaningful clinical algorithm to guide STI testing in asymptomatic men. The mathematical modelling and cost-effectiveness analysis of removing all asymptomatic urethral microscopy screening suggests that this would result in a small rise in adverse outcomes such as PID but that it would be highly cost-effective. APT appears to improve outcomes of partner notification in community settings but outcomes still fail to meet national standards. Priorities for future work include improving understanding of men’s collective behaviours and how these can be harnessed to improve health outcomes; exploring barriers to and facilitators of opportunistic STI screening for men attending general practice, with development of evidence-based interventions to increase the offer and uptake of screening; further development of APT for community settings; and studies to improve knowledge of factors specific to screening men who have sex with men (MSM) and, in particular, how, with the different epidemiology of STIs in MSM and the current narrow focus on chlamydia, this could negatively impact MSM’s sexual health.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Claudia Estcourt
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
- Barts Health NHS Trust, London, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Lorna Sutcliffe
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Catherine H Mercer
- Research Department of Infection and Population Health, University College London, London, UK
| | - Andrew Copas
- Research Department of Infection and Population Health, University College London, London, UK
| | - John Saunders
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
- Barts Health NHS Trust, London, UK
| | - Tracy E Roberts
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Sebastian S Fuller
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
- Public Health England, London, UK
| | - Louise J Jackson
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Andrew John Sutton
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Peter J White
- Medical Research Council Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
- Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Ruthie Birger
- Medical Research Council Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Greta Rait
- PRIMENT Clinical Trials Unit, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Anne Johnson
- Research Department of Infection and Population Health, University College London, London, UK
| | - Graham Hart
- Research Department of Infection and Population Health, University College London, London, UK
| | - Pamela Muniina
- Research Department of Infection and Population Health, University College London, London, UK
| | - Jackie Cassell
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, University of Brighton, Brighton, UK
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Town K, McNulty CAM, Ricketts EJ, Hartney T, Nardone A, Folkard KA, Charlett A, Dunbar JK. Service evaluation of an educational intervention to improve sexual health services in primary care implemented using a step-wedge design: analysis of chlamydia testing and diagnosis rate changes. BMC Public Health 2016; 16:686. [PMID: 27484823 PMCID: PMC4969638 DOI: 10.1186/s12889-016-3343-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 06/15/2016] [Indexed: 11/24/2022] Open
Abstract
Background Providing sexual health services in primary care is an essential step towards universal provision. However they are not offered consistently. We conducted a national pilot of an educational intervention to improve staff’s skills and confidence to increase chlamydia testing rates and provide condoms with contraceptive information plus HIV testing according to national guidelines, known as 3Cs&HIV. The effectiveness of the pilot on chlamydia testing and diagnosis rates in general practice was evaluated. Methods The pilot was implemented using a step-wedge design over three phases during 2013 and 2014 in England. The intervention combined educational workshops with posters, testing performance feedback and continuous support. Chlamydia testing and diagnosis rates in participating general practices during the control and intervention periods were compared adjusting for seasonal trends in chlamydia testing and differences in practice size. Intervention effect modification was assessed for the following general practice characteristics: chlamydia testing rate compared to national median, number of general practice staff employed, payment for chlamydia screening, practice urban/rurality classification, and proximity to sexual health clinics. Results The 460 participating practices conducted 26,021 tests in the control period and 18,797 tests during the intervention period. Intention-to-treat analysis showed no change in the unadjusted median tests and diagnoses per month per practice after receiving training: 2.7 vs 2.7; 0.1 vs 0.1. Multivariable negative binomial regression analysis found no significant change in overall testing or diagnoses post-intervention (incidence rate ratio (IRR) 1.01, 95 % confidence interval (CI) 0.96–1.07, P = 0.72; 0.98 CI 0.84–1.15, P = 0.84, respectively). Stratified analysis showed testing increased significantly in practices where payments were in place prior to the intervention (IRR 2.12 CI 1.41–3.18, P < 0.001) and in practices with 6–15 staff (6–10 GPs IRR 1.35 (1.07–1.71), P = 0.012; 11–15 GPs IRR 1.37 (1.09–1.73), P = 0.007). Conclusion This national pilot of short educational training sessions found no overall effect on chlamydia testing in primary care. However, in certain sub-groups chlamydia testing rates increased due to the intervention. This demonstrates the importance of piloting and evaluating any service improvement intervention to assess the impact before widespread implementation, and the need for detailed understanding of local services in order to select effective interventions. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3343-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katy Town
- HIV/STI Department, National Infection Service, Public Health England, London, UK.
| | - Cliodna A M McNulty
- Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Gloucester, UK
| | - Ellie J Ricketts
- Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Gloucester, UK
| | - Thomas Hartney
- HIV/STI Department, National Infection Service, Public Health England, London, UK
| | - Anthony Nardone
- HIV/STI Department, National Infection Service, Public Health England, London, UK
| | - Kate A Folkard
- HIV/STI Department, National Infection Service, Public Health England, London, UK
| | - Andre Charlett
- Statistics, Modelling and Economics Department, Public Health England, 61 Colindale Avenue, NW9 5EQ, London, UK
| | - J Kevin Dunbar
- HIV/STI Department, National Infection Service, Public Health England, London, UK
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Estcourt CS, Sutcliffe LJ, Copas A, Mercer CH, Roberts TE, Jackson LJ, Symonds M, Tickle L, Muniina P, Rait G, Johnson AM, Aderogba K, Creighton S, Cassell JA. Developing and testing accelerated partner therapy for partner notification for people with genital Chlamydia trachomatis diagnosed in primary care: a pilot randomised controlled trial. Sex Transm Infect 2015; 91:548-54. [PMID: 26019232 PMCID: PMC4680194 DOI: 10.1136/sextrans-2014-051994] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 05/05/2015] [Indexed: 11/07/2022] Open
Abstract
Background Accelerated partner therapy (APT) is a promising partner notification (PN) intervention in specialist sexual health clinic attenders. To address its applicability in primary care, we undertook a pilot randomised controlled trial (RCT) of two APT models in community settings. Methods Three-arm pilot RCT of two adjunct APT interventions: APTHotline (telephone assessment of partner(s) plus standard PN) and APTPharmacy (community pharmacist assessment of partner(s) plus routine PN), versus standard PN alone (patient referral). Index patients were women diagnosed with genital chlamydia in 12 general practices and three community contraception and sexual health (CASH) services in London and south coast of England, randomised between 1 September 2011 and 31 July 2013. Results 199 women described 339 male partners, of whom 313 were reported by the index as contactable. The proportions of contactable partners considered treated within 6 weeks of index diagnosis were APTHotline 39/111 (35%), APTPharmacy 46/100 (46%), standard patient referral 46/102 (45%). Among treated partners, 8/39 (21%) in APTHotline arm were treated via hotline and 14/46 (30%) in APTPharmacy arm were treated via pharmacy. Conclusions The two novel primary care APT models were acceptable, feasible, compliant with regulations and capable of achieving acceptable outcomes within a pilot RCT but intervention uptake was low. Although addition of these interventions to standard PN did not result in a difference between arms, overall PN uptake was higher than previously reported in similar settings, probably as a result of introducing a formal evaluation. Recruitment to an individually randomised trial proved challenging and full evaluation will likely require service-level randomisation. Trial registration number Registered UK Clinical Research Network Study Portfolio id number 10123.
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Affiliation(s)
- Claudia S Estcourt
- Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Lorna J Sutcliffe
- Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Andrew Copas
- Research Department of Infection & Population Health, University College London, London, UK
| | - Catherine H Mercer
- Research Department of Infection & Population Health, University College London, London, UK
| | - Tracy E Roberts
- Health Economics Unit, School of Population and Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Louise J Jackson
- Health Economics Unit, School of Population and Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Merle Symonds
- Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Laura Tickle
- Barts Sexual Health Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Pamela Muniina
- Research Department of Infection & Population Health, University College London, London, UK
| | - Greta Rait
- Research Department of Infection & Population Health, University College London, London, UK
| | - Anne M Johnson
- Research Department of Infection & Population Health, University College London, London, UK
| | - Kazeem Aderogba
- Department of Sexual Health, Eastbourne District General Hospital, East Sussex Healthcare NHS Trust, Eastbourne, UK
| | - Sarah Creighton
- Homerton Sexual Health Services, Homerton Hospital, London, UK
| | - Jackie A Cassell
- Division of Primary Care & Public Health, Brighton & Sussex Medical School, University of Brighton, Brighton, UK
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Jackson LJ, Roberts TE, Fuller SS, Sutcliffe LJ, Saunders JM, Copas AJ, Mercer CH, Cassell JA, Estcourt CS. Exploring the costs and outcomes of sexually transmitted infection (STI) screening interventions targeting men in football club settings: preliminary cost-consequence analysis of the SPORTSMART pilot randomised controlled trial. Sex Transm Infect 2014; 91:100-5. [PMID: 25512670 PMCID: PMC4345770 DOI: 10.1136/sextrans-2014-051715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The objective of this study was to compare the costs and outcomes of two sexually transmitted infection (STI) screening interventions targeted at men in football club settings in England, including screening promoted by team captains. METHODS A comparison of costs and outcomes was undertaken alongside a pilot cluster randomised control trial involving three trial arms: (1) captain-led and poster STI screening promotion; (2) sexual health advisor-led and poster STI screening promotion and (3) poster-only STI screening promotion (control/comparator). For all study arms, resource use and cost data were collected prospectively. RESULTS There was considerable variation in uptake rates between clubs, but results were broadly comparable across study arms with 50% of men accepting the screening offer in the captain-led arm, 67% in the sexual health advisor-led arm and 61% in the poster-only control arm. The overall costs associated with the intervention arms were similar. The average cost per player tested was comparable, with the average cost per player tested for the captain-led promotion estimated to be £88.99 compared with £88.33 for the sexual health advisor-led promotion and £81.87 for the poster-only (control) arm. CONCLUSIONS Costs and outcomes were similar across intervention arms. The target sample size was not achieved, and we found a greater than anticipated variability between clubs in the acceptability of screening, which limited our ability to estimate acceptability for intervention arms. Further evidence is needed about the public health benefits associated with screening interventions in non-clinical settings so that their cost-effectiveness can be fully evaluated.
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Affiliation(s)
- Louise J Jackson
- Health Economics Unit, School of Population and Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tracy E Roberts
- Health Economics Unit, School of Population and Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sebastian S Fuller
- Centre for Immunology & Infectious Disease: Sexual Health & HIV, Blizard Institute, Queen Mary, University of London, Barts and the London School of Medicine and Dentistry, London, UK
| | - Lorna J Sutcliffe
- Centre for Immunology & Infectious Disease: Sexual Health & HIV, Blizard Institute, Queen Mary, University of London, Barts and the London School of Medicine and Dentistry, London, UK
| | - John M Saunders
- Health Economics Unit, School of Population and Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Centre for Immunology & Infectious Disease: Sexual Health & HIV, Blizard Institute, Queen Mary, University of London, Barts and the London School of Medicine and Dentistry, London, UK Centre for Sexual Health and HIV Research, Faculty of Population Health Sciences, University College London, London, UK Division of Primary Care & Public Health, Brighton and Sussex Medical School, University of Brighton, Falmer, Brighton, UK
| | - Andrew J Copas
- Centre for Immunology & Infectious Disease: Sexual Health & HIV, Blizard Institute, Queen Mary, University of London, Barts and the London School of Medicine and Dentistry, London, UK Centre for Sexual Health and HIV Research, Faculty of Population Health Sciences, University College London, London, UK
| | - Catherine H Mercer
- Centre for Sexual Health and HIV Research, Faculty of Population Health Sciences, University College London, London, UK
| | - Jackie A Cassell
- Division of Primary Care & Public Health, Brighton and Sussex Medical School, University of Brighton, Falmer, Brighton, UK
| | - Claudia S Estcourt
- Centre for Immunology & Infectious Disease: Sexual Health & HIV, Blizard Institute, Queen Mary, University of London, Barts and the London School of Medicine and Dentistry, London, UK
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