Cost-effectiveness and impact of five different point of care strategies to preserve last line treatment for gonorrhoea

Antimicrobial resistance (AMR) has developed to every class of antibiotic used for the treatment of gonorrhoea – and in recent years several multi-drug resistant strains of gonorrhoea have been reported in the UK and elsewhere. Once the prevalence of resistance to a first-line treatment reaches 5%, an alternative drug is selected as first-line treatment. In the UK, as with many other countries, ceftriaxone is the current first-line treatment for gonorrhoea. There are few alternative treatments available should ceftriaxone resistance become widespread and therefore steps are being taken to preserve the effectiveness of ceftriaxone by avoiding its use for infections that could be treated using other antibiotics.

Aquarius was commissioned by the Applied Diagnostic Research and Evaluation Unit (ADREU) at St. Georges London to compare the cost and effectiveness of five different strategies to test for antibiotic susceptibility in NG infections. We developed a decision tree model to assess how point-of-care (POC) testing could be used to diagnose gonorrhoea and at the same time test for antibody susceptibility, allowing the use of previously abandoned antibiotics for the majority of patients, thereby sparing ceftriaxone use.

The results of the model showed that all five strategies cost more than the current strategy of not testing for AMR. The paper concludes that AMR POC testing may enable improved antibiotic stewardship but would require investment into the health system.

The article was published in October in Eurosurveillance and is available free online [link].

Harding-Esch EM, Huntington SE, Harvey MJ, Weston G, Broad CE, Adams EJ, et al. Antimicrobial resistance point-of-care testing for gonorrhoea treatment regimens: cost-effectiveness and impact on ceftriaxone use of five hypothetical strategies compared with standard care in England sexual health clinics. Eurosurveillance [Internet]. 2020;25(43). Available from: https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.43.1900402

Examining the acceptability of offering STI screening in higher educational settings

Uptake of screening for STIs, such as chlamydia and gonorrhoea, is often inadequate in young people despite provision of open-access sexual health services. Offering STI tests outside medical settings is currently being explored as a way to increase uptake in this group.

In 2017, St George’s University of London ran the ‘Test n Treat’ feasibility trial where free, confidential on-site testing for chlamydia and gonorrhoea was offered to students at six higher-education colleges in South London. We have previously reported on the main results of the trial and the cost estimates of providing such a service .

As part of the trial, the research team wanted to understand the acceptability of this type of service among students as well as the barriers and facilitators to its use. They interviewed a small sample of students, some of whom used the service and some of whom did not, as well teachers and the research team. The results of this qualitative study, which Aquarius Population Health gave advisory support to, were published in August 2020.

The paper reports that students who used the service had a very positive opinion of it. There were a number of barriers to using the service identified, including embarrassment about STI testing and the perceived view that individuals would be viewed negatively by their peers if they had an STI test. On the flip side, peers also acted as facilitators to uptake, for example, if a group of friends encouraged each other to get tested. A lack of understanding of STIs was another major barrier, with many students lacking understanding about the long-term consequences of STIs or having the misconception that only people with symptoms should get tested.  Where a £5 honorarium was given to students using the service, this acted as a legitimate incentive for testing, mitigating the (perceived) social stigma of testing.

The paper concludes that if a similar service were provided in future, uptake could be improved if education about sexual health was offered alongside testing, if small cash incentives were given and if peer influencers were engaged to promote the service.

Fleming, C., Drennan, V.M., Kerry-Barnard, S. et al. Understanding the acceptability, barriers and facilitators for chlamydia and gonorrhoea screening in technical colleges: qualitative process evaluation of the “Test n Treat” trial. BMC Public Health 20, 1212 (2020). https://doi.org/10.1186/s12889-020-09285-1

Cost analysis of near patient chlamydia and gonorrhoea screening and treatment in further education/technical colleges

Aquarius collaborated with St George’s University of London on an NIHR-funded study, ‘Test n Treat’ (TnT). In this cluster randomised feasibility trial, rapid chlamydia (CT) and gonorrhoea (NG) testing and same day on-site chlamydia treatment in six technical colleges in South London was delivered. 

Using process data from the trial (the main results of which were published last year) and NHS cost data, the overall cost of providing the TnT service was calculated, as well as the cost per CT/NG screen and the cost per CT/NG infection diagnosed. These took into account the fixed daily costs, such as staff time and equipment use, and the per screen costs, i.e. the consumables used to collect and test samples, and were dependent on uptake of screening. Since the average cost per screen was higher if uptake was low as per what was observed in the trial, and lower if uptake was high, costs for a range of update scenarios were assessed. If daily capacity for screening was achieved (calculated as 49 screens/day), the cost per screen was £47 (including the £10 incentive given to students to encourage participation). This increased to £91, if uptake was equivalent to the average uptake observed on the trial (19 screens/day). The paper concluded that delivering this type of service is more expensive per person than CT and NG screening in sexual health clinics but could be more comparable in areas of high CT/NG prevalence.

Publication

Kerry-Barnard S, Huntington, S, Fleming C, et al. Near patient chlamydia and gonorrhoea screening and treatment in further education/technical colleges: a cost analysis of the ‘Test n Treat’ feasibility trial. BMC Health Services Research. https://doi.org/10.1186/s12913-020-5062-5

Modelling cost-effectiveness of multipathogen POC tests for sexually transmitted infections

In this BMJ Open article, we report on health economic modelling results that compare three possible strategies for point-of-care (POC) sexually transmitted infection (STI) testing with the current practice of microscopy and lab-based testing.  Results showed that testing for STIs with either a dual, triple or quadruple POC test provided more patient benefit than current practice but may cost more. The quadruple POC test was the least expensive POC strategy relative to standard care – with an incremental cost-effectiveness ratio of £36,585 per quality adjusted life years gained, when taking the clinic’s perspective. When taking the commissioners’ perspective, who pay for the services delivered through tariffs, over £26 million in savings could be achieved using the 4-bug test, mainly because patients were treated appropriately on their first testing visit rather than having to re-attend.

 

PublicationHuntington SE, Burns RM, Harding-Esch E, et al.  ‘Modelling-based evaluation of the costs, benefits and cost-effectiveness of multipathogen point-of-care tests for sexually transmitted infections in symptomatic genitourinary medicine clinic attendees.’ BMJ Open 2018;8:e020394. doi:10.1136/bmjopen-2017-020394

To request a copy of the published article, please email caroline.dombrowski@aquariusph.com.

Test n Treat – rapid STI testing and treatment in colleges: study protocol

Sexually active young people attending London further education (FE) colleges have high rates of chlamydia, but screening rates are low. We describe the study protocol for “Test and Treat” (TnT), an NIHR-funded research study. This is a cluster randomised feasibility trial of frequent, rapid, on-site chlamydia testing using the Cepheid GeneXpert system and same-day treatment in six FE colleges. As part of the study we also conducted qualitative and economic assessments to assess the feasibility of conducting a future large-scale trial to investigate if TnT reduces chlamydia rates. The methods for recruitment, participant data collection, sample collection and testing are described, for baseline and follow-up in the control and intervention groups. The statistical analysis plan for TnT has been published separately.

 

PublicationKerry-Barnard S, Fleming C, Reid F, et al. ‘Test n Treat (TnT)’- Rapid testing and same-day, on-site treatment to reduce rates of chlamydia in sexually active further education college students: study protocol for a cluster randomised feasibility trial. Trials. 2018 Jun 5;19(1):311. doi: 10.1186/s13063-018-2674-8.

To request a copy of the published article, please email caroline.dombrowski@aquariusph.com.

Rapid testing and treatment for sexually transmitted infections improve patient care and yield public health benefits

With collaborators at Chelsea and Westminster NHS Foundation Trust, we estimated the impact of a rapid testing and result notification service for patients testing for sexually transmitted infections at the Dean Street Express clinic. We found that a rapid testing service for asymptomatic infections resulted in 8 days’ faster time to result notification for CT and/or NG which enables faster treatment, thus reducing infectious periods and leading to fewer transmissions, unnecessary partner attendances and clinic costs, compared with those attending an existing ‘standard’ sexual health clinic.

PublicationWhitlock GG, Gibbons DC, Longford N, et al. Rapid testing and treatment for sexually transmitted infections improve patient care and yield public health benefits
International Journal of STD & AIDS. First Published October 23, 2017
https://doi.org/10.1177/0956462417736431

 

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Cost-effectiveness of antimicrobial resistance point-of-care testing for optimising gonorrhoea treatment

In July, Emma Harding-Esch spoke at the STI and HIV World Congress in Rio on how to best manage the increasing challenge of anti-microbial resistance (AMR). The research she presented was a collaboration between Aquarius Population Health and ADREU St. Georges.  In recent years, there has been an increase in resistance to first-line therapies used to treat STIs such as gonorrhoea. The Aquarius team built a decision tree model to assess the cost-effectiveness of standard care compared to several hypothetical rapid point-of-care tests (POCT) for antibiotic susceptibility. The model simulated a cohort of sexual health clinic attendees. The results showed that while standard care is the cheapest option, AMR POCTs may be cost-effective and maximise the number of effective agents in treatment regimens, providing long-term benefits in some scenarios.

Harding-Esch EM, Huntington SE, Harvey MJ, et al. Cost-effectiveness of antimicrobial resistance point-of-care testing for optimising the treatment of gonorrhoea STI & HIV World Congress. 9-12 July 2017. Rio de Janiero, Brazil.

 

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Evaluating the costs, benefits and cost-effectiveness of multi-pathogen point-of-care tests for sexually transmitted infections

Evaluating multi-bug point-of-care tests for sexually transmitted infections

We estimated costs, benefits and cost-effectiveness of three accurate 30-minute NAAT POCT strategies that detect different STI combinations, compared with standard care  (laboratory-based NAAT for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG)).  We found the CT-NG-MG-TV POCT strategy was the cheapest using tariff costing. It offered the most benefits, which in turn may have wider public health impacts through rapid and accurate STI diagnosis and management. Different testing strategies may be more cost-effective in different SHCs and patient groups. Further evidence is needed to capture the diversity of STI prevalence and management of patients across clinical services to better inform economic analyses.

presentation_icon
Harding-Esch EM, Huntington SE, Burns RM, et al. Evaluating the costs, benefits and cost-effectiveness of multi-pathogen point-of-care tests for sexually transmitted infections STI & HIV World Congress. 9-12 July 2017. Rio de Janiero, Brazil.

 

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Modelling how point-of-care tests can enable personalised treatment for resistant gonorrhoea infections

We created a mathematical model to investigate the treatment impact and economic implications of introducing an antimicrobial resistance point-of-care test (AMR POCT) for gonorrhoea as a way of extending the life of current last-line treatments. The introduction of AMR POCT could allow clinicians to discern between the majority of gonorrhoea-positive patients with strains that could be treated with older, previously abandoned first-line treatments, and those requiring our current last-line dual therapy. Such tests could extend the useful life of dual ceftriaxone and azithromycin therapy, thus pushing back the time when gonorrhoea may become untreatable.

Publication

Turner KM, Christensen H, Adams EJ, et al Analysis of the potential for point-of-care test to enable individualised treatment of infections caused by antimicrobial-resistant and susceptible strains of Neisseria gonorrhoeae: a modelling study
BMJ Open 2017;7:e015447. doi: 10.1136/bmjopen-2016-015447

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The benefits and cost-savings of a new point-of-care test for chlamydia and gonorrhoea

Problem: Cepheid’s Xpert® CT/NG test is a high performance point-of-care test for chlamydia and gonorrhoea, and offers a promising advance in the diagnosis and control of two common sexually transmitted infections. When the test was launched in 2013, Cepheid wanted to understand how sexual health clinics in England might use it and to develop evidence comparing its costs and benefits to standard laboratory tests.

Approach: We approached the challenge in two projects. For the first, we defined the current patient pathways for chlamydia and gonorrhoea testing treatment and compared them to what they would be if a rapid POCT was used. We held workshops with staff in four sexual health clinics, asking them to map out the current patient pathways for chlamydia and gonorrhoea diagnosis and treatment. We then helped them brainstorm ways in which their services might include a point-of-care chlamydia and gonorrhoea test, and describe how this would change their patient pathways. Finally, we used Dots, our cloud-based pathway builder tool, build to estimate the costs of the pathways. The work indicated that the pathways could be streamlined with a point-of-care test, and we estimated that this would cost less to deliver than current practice.

For the second project, we developed an economic model to compare the overall costs and benefits of a point-of-care test to standard care. We combined the results of our first project with previous work our team had conducted on chlamydia and gonorrhoea testing and management. The model showed that the test could deliver £10million in cost savings, and give far more effective management of chlamydia and gonorrhoea at a population level. Our results were published in Sexually Transmitted Infections, and have been presented at national and international conferences.

Impact: Our work gave Cepheid the empirical evidence to demonstrate the value and potential impact of adopting their test in clinics. Since our projects, Cepheid has had increasing interest in the test, and several centres have purchased it. This includes a major London sexual health clinic which has introduced a new testing service as a result.

 

Testimonial

“I started working with Aquarius in 2012. Elisabeth and her team have always delivered great results, including 2 peer-reviewed publications, that add real value and insight, and they come up with creative ways to answer our questions. I enjoy collaborating with them and look forward to continuing our work on a range of disease areas in the future.”

  • Dr. Anne Postulka, Senior Director Medical & Economic Value, Cepheid

 

Related publications

publication_iconAdams EJ, Ehrlich A, Turner KME, et al. Mapping patient pathways and estimating resource use for point of care versus standard testing and treatment of chlamydia and gonorrhoea in genitourinary medicine clinics in the UK. BMJ Open 2014;4: e005322. doi:10.1136/bmjopen-2014-005322

publication_iconTurner KME, Round J, Horner PJ, et. al. What are the clinical and economic costs and benefits of implementing point of care NAAT tests for Chlamydia trachomatis and Neisseria gonorrhoeae in genitourinary medicine clinics in England? Sex Transm Infect. Published online 22 Nov 2013: doi:10.1136/sextrans-2013-051147

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