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Reinfection

Trialling innovative approaches to STI partner services: Partner-Delivered vv. Accelerated Partner Therapy

26 Feb, 15 | by Leslie Goode, Blogmaster

It is vital to treat partners of patients with curable STIs as quickly as possible.  But the effectiveness of interventions to achieve this proves hard to measure – and the case for increasing resources correspondingly difficult to make.  The inadequacy of the resources available to existing partner services has led some investigators in the US and UK to seek out innovative approaches to ensuring the treatment of partners which are less expensive.  One option – Patient-Delivered Partner Therapy (PDPT) – is to provide treatment for partners via the patient and without prior medical assessment of the partner.  The problems with this are: first, that PDPT may not conform to legal (Cramer & Leichliter (STI)) or professional guidelines; second, that concomitant infections (e.g. HIV) in the partner may go undiagnosed and untreated. An alternative solution – Accelerated Partner Therapy (APT) – is to treat the partner via the patient, but only after a medical assessment conducted by telephone or with a pharmacist (Golden & Estcourt (STI); Dombrowski & Golden (STI)).

The option of PDPT has been trialled in various US clinics (Mickievicz & Rietmeijer (STI); Sanchez & Schillinger (STI); but its impact is difficult to evaluate on a local level. Now, for the first time, Golden & Holmes have attempted a population-level randomized control trial of uptake and impact across 23 out of the 25 counties of Washington State.  This impressively large-scale operation had two elements.  The first was the provision of free PDPT, and involved: 1. informing all clinicians about the programme; 2. making stocks of free PDPT available to clinicians who had reported ≥ one case of Chlamydia or Gonorrhoea, and to certain large pharmaceutical chains; 3. visiting clinicians reporting frequent cases for the purpose of educating staff about the programme.  The second element was the possibility offered to diagnosing practitioners via routine report forms of having the provision of partner services handled by the state public health department. This intervention was rolled out in four successive waves to different counties in turn, thus enabling the impact of the intervention to be controlled against the default situation in the counties of each wave.

As regards uptake, percentage of persons receiving PDPT from clinicians rose in intervention periods from 18% to 34%, and percentage receiving partner services from 25% to 45%.  This is broadly comparable with what has been achieved by more local interventions in the US.  Unfortunately, it is one thing for a pack to be accepted by the index patient, another for a partner to be successfully treated.  Hence the interest of G&S’s attempt to evaluate population-level impact – through testing in sentinel clinics in the case of Chlamydia, and through incidence of reported infection in the case of Gonorrhoea. It was undoubtedly ambitious of G&S to seek an indicator of population level impact for a comparatively brief intervention.  It is no surprise that the results are less than overwhelming. Chlamydia test positivity and gonorrhoea incidence in women declined respectively from 8.2% to 6.5% and from 59.6 to 26.4 per 100,000. The latter more impressive reduction is unfortunately hard to distinguish from a strong secular trend in the same direction in various states.

There are more general problems, however – such as knowing whether the handing over of PDPT packs is resulting in the successful treatment of disease, or whether it may even be contributing to an ongoing failure to diagnose concomitant partner infections.  These might weigh in favour of the alternative approach recently developed in UK clinics: APT.  Estcourt & Johnson (STI) report uptakes of 66% and 59% for versions of APT as against 36% for conventional PS.  Sending a treatment pack following a telephone interview would seem to offer a better guarantee of partner treatment, than offering a pack on the basis of nothing more than a stated willingness of the index patient to deliver it.  At the same time, interviewing the partner averts the risk of doing harm by pre-empting consultations at which a fuller diagnosis of the partner’s condition would have been possible.  A population-level trial of the impact of APT has yet to be undertaken.

Could Chlamydia treatment failure be the result of genital contamination from persistent gut infection

6 Mar, 14 | by Leslie Goode, Blogmaster

The persistence of Chlamydia trachomatis  (Ct) infection in treated patients is generally attributed either to re-infection or poor treatment adherence.  To some, however, the evidence has suggested the operation of an additional factor – such as treatment failure (STIs/ Goetz & Bruisten; STIs/ Pitt & Ison; STIs/ Horner).

A recent study (Rank & Yeruva (R&Y)) develops an interesting hypothesis, based on evidence of Ct. infection in the gastro-intestinal (GI) tract of mice.  This supports the possibility that Ct. persistence in humans might be a result of ongoing Ct. infection of the gut, and re-infection of the genital via the lower GI tract (Yeruva & Rank).  According to R&Y’s research on animals, Ct. of the GI tract does not elicit an inflammatory response, and never resolves.  It provokes an immune response – but not at a level that would cure the GI infection.  The orthodoxy states that Ct. found in the human GI tract is “non-replicating”.  R&Y claim this not based on evidence.  So they see nothing to exclude the possibility that, in humans, as in mice, treatment failure may be due to auto-innoculation from the lower GI tract.

This hypothesis is highly relevant to discussion of Ct. persistence in this journal, which has arisen around such questions as: whether persistence is due to some factor other than re-infection or poor adherence, such as anti-microbial resistance (STIs/ Goetz & Bruisten; STIs/ Pitt & Ison); how important that factor is, and what it means for Chlamydia screening programs (STIs/ Regan & Hocking).  If R&Y’s hypothesis proves valid for humans as for mice, then that other factor – or, at least, some element of it – is explained, and would certainly need to be taken account of when modelling the effectiveness of screening programs.

The idea that persistence of Ct. in humans results from contamination from persistent GI tract infection seems to be a new one in the STI literature (though apparently cases have been documented by the veterinary literature in numerous animals as early as the 1950s).  It is certainly worthy of further investigation, given the implications that it would have, if proven, for diagnosis and management of human Ct. infection.  In that event, it would be necessary to consider, for example, what importance to attach to the clearing Ct. from the GI tract – and, supposing this to be necessary, how this would affect the nature and duration of treatment given for genital Ct..  In treating rectal Ct., for example, treatment with Azithromycin (≤13%) has been claimed to be inadequate (STIs/ Drummond & Donovan), while Hathorn & Goold find treatment with doxycycline to be a more effective alternative (STIs/ Hathorn & Goold).

Call for Papers: Reinfection and Retesting

9 Nov, 11 | by BMJ

We invite submissions for a special issue to be published in 2012 which will address the topics of Reinfection and Re-testing for STis and HIV.  The Guest Editors for this important publication will be Dr Matthew Golden (Seattle, USA) and Dr Katy Turner (Bristol, UK).

In this issue we aim to bring together a wide range of original peer-reviewed research, editorial and review  which will explore cutting edge issues relating to reinfection and re-testing.  The issue will be accompanied by freely available podcasts and blog material, providing an excellent opportunity to maximise the global impact of your research.

The deadline for initial submission will be 1st January 2012.  If you have any questions about this issue, or wish to discuss your submission (e.g. whether to choose a full length research paper or a short report), please feel free to contact our Guest Editors at golden@u.washington.edu or Katy.Turner@bristol.ac.uk.  Our main website page gives a link to our Instructions for Authors, which will be unchanged for this special issue.

When submitting your paper, please choose the article type “Reinfection and Retesting”.

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