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

Cluster-randomised feasibility trial of a chlamydia test and treat (TnT) service in further education colleges

Aquarius were involved in a recent cluster-randomised feasibility trial looking at whether provision of a same day test and treatment (TnT) service for chlamydia in further education colleges could be used to improve uptake of chlamydia testing in sexually active 16-24 year olds. The trial found that despite a high prevalence of chlamydia among sexually active students at the colleges, uptake of the free confidential TnT service was low. At the three colleges, 13% of students were tested when the service was first offered and 10% when it was offered again three months later. Interviews with students revealed that low uptake was associated with not feeling at risk of a sexually transmitted infection, perceptions of stigma, and lack of knowledge about sexually transmitted infections, while all students interviewed were positive about the TnT service itself.

PublicationOakeshott P, Kerry-Barnard S, Fleming C, et al. “Test n Treat” (TnT): a cluster randomised feasibility trial of on-site rapid Chlamydia trachomatis tests and treatment in ethnically diverse, sexually active teenagers attending technical colleges. Clinical Microbiology and Infection. https://doi.org/10.1016/j.cmi.2018.10.019.

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.’ 

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

Enabling more efficient patient management of blood stream infections

The Guardian supplement ‘Acting on AMR’, was published in March 2018, and focused on a number of ways to improve antimicrobial stewardship. This supplement included an article by Momentum Bioscience, which highlighted the importance of using technology to enable earlier rule-out of blood stream infections.

In addition to the benefits to patients, Aquarius conducted an economic analysis for Momentum Bioscience to estimate the impact if the test is used on neonates with suspected sepsis. Our estimates showed that if the test is used on all babies born in England, an estimated £6 million could be saved, with a significant reduction in the antibiotics used and length of stay of babies who were free from infection.

Publication Bennett, H  ‘How do we enable more efficient patient management and antibiotic stewardship?’ MediaPlanet (an independent supplement distributed in The Guardian) March 2018 p5.

 

 

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Assessing the impact of point-of-care testing for influenza and respiratory syncytial virus in children admitted to hospital

We assessed the impact and economic benefits of using a point-of-care (POC) assay instead of standard laboratory testing to detect influenza and respiratory syncytial virus (RSV) in children and infants admitted to hospital . This real-world evaluation was conducted in two subsequent ‘flu seasons at the Evelina Children’s Hospital in London. Results showed that following the introduction of the POC testing, children with influenza were more likely to receive oseltamivir treatment, the antiviral recommended for influenza. Although there was no statistically significant reduction in the average length of hospital admission or in the number of antibiotics prescribed, there was a reduction in laboratory costs and in reimbursement charges for hospital admissions suggesting that use of the POC assay resulted in fewer procedures and interventions performed during admissions.

Publication Vecino-Ortiz AI, Goldenberg SD, Douthwaite ST, et alImpact of a multiplex PCR point-of-care test for influenza A/B and respiratory syncytial virus on an acute pediatric hospital ward. Diagnostic Microbiology and Infectious Disease,  Volume 91, Issue 4, August 2018, Pages 331-335. 

 

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

 

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Using real world evidence to characterise a cohort of metastatic uveal melanoma patients in England

We identified a cohort of uveal melanoma (UM) and metastatic uveal melanoma (mUM) patients within England using the Hospital Episodes Statistics database, which had similar characteristics to other cohorts identified in the clinical literature.

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Schwenkglenks M, Alamgir G, Cheng CY, et al. A real world evidence (RWE) approach to characterising an ultra-rare disease (URD) cohort of metastatic uveal melanoma (mUM) patients within National Health Service England (NHSE). International Society for Pharmacoeconomics and Outcomes Annual European Congress. 4-8 November 2017. Glasgow, Scotland, UK.

 

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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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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

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Point-of-care tests for infectious diseases: Barriers to implementation across three London teaching hospitals

Our paper explores results of the acceptability and implementation issues of point of care tests (POCTs) in paediatric patients in three south London hospitals. Overall, we found that having a test result was thought to improve bed management and cohorting sick patients appropriately, reassure parents about their child’s condition, reduce hospital transmission, and rationalise further tests and treatment. Concerns focused on confidence about the test’s performance – particularly around false negatives not receiving proper management, how to manage discrepant results (i.e. the laboratory assay gave a different answer to the POCT), and training enough staff to run the test at the point of care.

Publication

Bustinduy AL, Jeyaratnam D, Adams EJ, et al. CLAHRC South London; Paediatric Infection Network. Point-of-care tests for infectious diseases: Barriers to implementation across three London teaching hospitals. Acta Paediatrica,  April 2017. DOI: 10.1111/apa.13867

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