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role of IT systems

How Mobile Technology Can Lead to Improved Care of STIs – by Julie Potyraj

16 Aug, 16 | by Leslie Goode, Blogmaster

Blog by Julie Potyraj, Community Manager, Milken Institute School of Public Health at The George Washington University

e: jpotyraj@publichealthonline.gwu.edu

As we move into an era where our phones do everything from lowering the temperature in our homes to arranging a ride, it comes as no surprise that these devices also offer a new way to meet and engage with potential sexual partners. Along with the rise in popularity of dating apps, there has been an increase the incidence of sexually transmitted infections. In 2014 the CDC received the highest number of reports in history for chlamydia, syphilis, and gonorrhea in the United States. The challenge is to figure out a way to use technology to safeguard our sexual health in addition to meeting new partners.

In an effort to encourage online daters to get tested, a study published in Sexual Health posted advertisements for free HIV test kits on the dating website Grindr. In exchange for providing personal information about their health status and behaviors, participants received a free test kit. Not only did this intervention encourage HIV testing, but the study also showed an increase in the number of young men seeking treatment. Even a few of the volunteers who helped with the study became aware of their statuses.

The Grindr study shows that the privacy and comforts of home testing can be a desirable alternative to visiting a doctors’ office. Providing this alternative could potentially increase the number of people seeking testing for STIs. Improved testing technology used in tandem with the convenience and range of a mobile device introduces the opportunity to connect huge numbers of people with diagnostic interventions. The more people who get tested, the more data there is available. If this trend continues, we can anticipate an incredible expansion in electronic reporting, STI surveillance, and the use of this data in health informatics.

Mobile technology contributes to the collection of big data, which is defined as complex data sets that are so large that they cannot be evaluated by traditional data management tools. With better surveillance of STIs, medical providers can reach and identify commonly overlooked demographics by tracking trends to improve diagnostic care, interventions, patient outcomes, and cost of care.

More widely available data about STI outbreaks and incidence rates could help health care providers to make more informed medical decisions. For example, a care provider who identifies chlamydia from a patient’s urine could use big data to inform her decision about what type of antibiotic to prescribe. She may find there is an increasing incidence of azithromycin-resistant chlamydia in her city or state. Her awareness of this emerging trend would lead her to prescribe her patient with doxycycline instead; providing better medical care through informed treatment decisions.

The use of mobile technology can broaden epidemiologic surveillance and trend analysis of STI infections, offering knowledge to care providers that is otherwise unobtainable. More people using STI diagnostic interventions leads to the more people being tested and in turn better access to STI statistics. Mobile technologies, and health interventions that make use of them, can contribute to the collection of timely, relevant data. The analysis and interpretation of this data offers the possibility of improving health care quality and outcomes for patients.

Julie Potyraj

Myth or reality? Are social media triggering an explosion in sexually transmitted infections?

23 Jul, 15 | by Leslie Goode, Blogmaster

On the whole, where STIs are concerned, social media have tended to be considered as a potential force for the good in public health, offering a new resource for the management of HIV patients, or opportunities for disseminating health messages via peer education (Swanton & Mullan (STIs); Peer group education (STIs/blog)).  Recently, however, there have been a number of studies that have drawn attention to the negative implications of social media.  Last June a study by Beymer & Morisky (STIs), based on data on MSM attendees at the Los Angeles Gay and Lesbian Centre, concluded that, among the 7,000 participants, those who had used geo-sexual networking apps to meet up with a partner had greater odds for testing positive for gonorrhoea (OR 1.25) or chlamydia (OR 1.37) than those who employed in-person methods.

Recently, this more negative side has been receiving ever more attention in the US, especially in connection with HIV transmission.  A yet unpublished but widely publicized study, Agarwal and Greenwood (A&G), investigates hospital attendances for asymptomatic HIV (including acute and silent phases of the infection)  in Florida over the period 2002-2006 when the piece-meal introduction of the digital commerce platform, Craigslist, appears to have greatly facilitated on-line social transactions through its “casual encounters” forum.  It has also offered researchers the chance to record what they describe as a “natural experiment”, as successive counties have experienced the effects of entry into the platform.  A&G estimate the health “penalty” of entry into Craigslist at a 13.5% increase in attributable HIV infections – equivalent in financial terms to an additional burden of $592 million on the State of Florida.   This finding has recently been cited in connection with the precipitous rise in STIs in Rhode Island recently reported in an official Rhode Island Goverment press release and in the press coverage (Huffington Post) – 79% in syphilis; 30% in gonorrhoea; 33% in HIV over the year 2013-2014.

But A&G are concerned with more than estimating the magnitude of the effect.   The recent paper also claims to be the first study to attempt to determine exactly where that penalty of increased HIV infection due to social networking is actually falling – a question that is evidently of great interest to public health specialists who need to be able to target their interventions.  On the face of it, this is something of a puzzle.  HIV appears to be most heavily concentrated amongst the very sectors of the population who are most digitally disadvantaged.  So what could be going on?  To answer this question, A&G seek to disaggregate the Craigslist effect by ethnicity, income-level (as determined by enrolment in Medicaid) and gender.  What emerges from their analysis is that the effect of Craigslist entry is contained almost exclusively within the Afro-Caribbean (as opposed to Latino or “Caucasian”) population.  A&G seek to explain this apparently disproportionate penalty accruing to the digitally disadvantaged.  They argue that the “digital divide” is probably not “binary”, but more like a continuum.  We should not, in other words, necessarily think of “digital disadvantage” – at least for an important proportion of the disadvantaged – in terms of the total absence of access or skill.  It is therefore conceivable that it should be associated with a negative effect, i.e. the increased HIV incidence following Craigslist entry.  “Digital disadvantage”, they argue, is likely to be a matter of the limited capacity to utilize on-line resources for “welfare-enhancing activities” rather than a total unavailability of those resources.

 

Should ART provision be decentralized to health centres in low and middle income countries?

12 Aug, 13 | by Leslie Goode, Blogmaster

With the realization of the value of ART as a means of preventing HIV transmission, the question of how best to retain HIV-diagnosed in care becomes all the more pressing.  Recent STI blogs have covered such topics as the potential role of computer-generated reminders in retaining patients (sti blogs03/05/13), as well as the re-engagement of patients lost to care in a developed world context (sti blogs17/06/13).  But what about the retention of the HIV diagnosed in limited-resource settings such as sub-Saharan Africa?  Here, the stakes seem even higher – given the severity of the epidemic, and likely obstacles to full engagement such the relative inaccessibility of medical facilities to poor people living in rural settings (sti-Fried & Eyles).  What is the evidence that decentralizing HIV care from hospitals to local health care centres or the community could help to improve retention in care, and thereby contribute to controlling the epidemic?

A recent systematic review (Kredo & Gardner) produced by the Cochrane Collaboration surveys the few studies that address this question, and its results have fed into the recent WHO guidelines (WHO 2013 ART guidelines).

The paper itself considers care options within the three general categories of “partial decentralization” (ART initiated by hospital, maintained by local health centre), “full decentralization” (ART both initiated and maintained by health centre), and “decentralization to the community” (ART initiated by hospital or health centre and maintained by the community).  The options are examined in regard to their impact on loss to care, mortality, and attrition (a combination of loss to care + mortality).

Most of the evidence surveyed (i.e. 12/16 studies) consists in retrospective cohort studies susceptible to various kinds of bias.  Consequently the evidence is largely graded low or very low quality.  However, the review flags up some moderate quality evidence that:

–           partial decentralization is associated with reduced attrition at 12mnths. (RR=0.46)

–          full decentralization is associated with reduced loss to care at 12 mnths. (RR=0.3)

–          decentralization to health centres and decentralization to the community have a similar impact on loss to care, mortality and attrition.

The low and very low quality evidence regarding other associations points almost entirely in the direction of decentralization having a positive impact on retention in care.

On this basis the WHO guidance on the operational aspects of HIV management proposes the de-centralization of ART delivery and its integration with maternal and child health clinics, along with other strategies to improve retention in HIV care and task-shifting to close human resource gaps.

The studies reviewed demonstrate that that decentralization is at least feasible.  However, the authors also remind us in their conclusion that the decentralizing measures, to which they refer, “were in the context of a range of support structures and investments to ensuring delivery, including training, supervision and additional devices such as computer-aided or checklist-based decision aids”.  The implication seems to be that, without such support structures and investments – which may be difficult to achieve in certain contexts (for an interesting parallel see: sti blog25/6/12) the benefits of decentralization cannot be counted on.

Computerized “clinical decision support systems” (CDSS): their potential for improving HIV follow-up in low-resource settings

3 May, 13 | by Leslie Goode, Blogmaster

Kit Fairley (http://sti.bmj.com/content/87/Suppl_2/ii25.full)  in this journal offers an overview of the many ways in which information technology can be used in the area of STIs.  This is most obviously through the role of electronic medical records (EMR); but also through the possibility these offer for clinical decision support systems that can be used to generate prompts and reminders.  Information Technology (IT) has also opened up possibilities such as computer assisted self-interviewing (http://sti.bmj.com/content/86/4/310.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e), provision of wider access to counselling services, facilitation of partner notification.  If Gaydos et al.  are on the right track (http://www.iwantthekit.org), IT may one day “completely change the way services are provided”.  A number of papers published by STIs have focussed on trialling short message system reminders for re-testing/re-screening.  These have been show to have some effectiveness in the area of Chlamydia screening (http://sti.bmj.com/content/89/1/11.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e; http://sti.bmj.com/content/89/1/16.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e; http://sti.bmj.com/content/87/Suppl_1/A258.3.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e) and in the area of MSM HIV retesting achieved a fourfold increase in uptake (http://sti.bmj.com/content/87/3/229.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e).

A recent randomized control (RCT) study from a USAID-funded paediatric referral clinic in Kenya (Were & Vreeman), however, points to one impressively fruitful application of IT to STIs which seems to have failed to attract the attention it deserves (http://pediatrics.aappublications.org/content/131/3/e789.abstract?sid=f4698a8a-9724-4227-8896-3a9f57f92729).  In limited resource settings the complex process of pediatric HIV follow-up seems particularly apt to benefit from EMRs that can generate prompts to clinicians – especially where such staff are less than adequately trained, or are subject to high rates of turn-over, or overwhelmed by patient demand.  The reminders generated through this clinical decision support system (CDSS) include PCR tests, CD4 tests, ARV reminders, as well as baseline chemistry & hematology studies, chest X-rays and malnutrition reminders.  The RCT study claims a nearly fourfold improvement in adherence to protocols overall – admittedly with some procedures (e.g. chest x-rays, laboratory tests other than ELISA) benefiting enormously more than others (e.g. initiation of ART ).  Of course, the effectiveness of such reminders, as the authors emphasize, ultimately depends on the quality of the input data informing the “summaries” from which reminders are generated.

The effectiveness of CDSS in this area seems less remarkable than the apparent absence of studies like that of Were & Vreeman.  The authors cite studies of the use of computer-based alerts and reminders for HIV care in the US, and a comparative study between 2 clinics of a system of computer-generated reminders for CD4 testing of adults.  But, “rigorously controlled trials of CDSS effectiveness in resource-limited settings could not be found”.  The authors conclude that pediatric HIV care in limited resource settings is one area where the application of technology has the potential dramatically to improve compliance with protocols.  Such a claim seems to warrant further investigation.

 

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