A service evaluation comparing home-based testing to clinic-based testing for HIV, syphilis and hepatitis B in Birmingham and Solihull.

The sexual health services in the Birmingham and Solihull area of the United Kingdom, called Umbrella, has been offering home-based testing for sexually transmitted infections to patients since August 2015. The aim of this service evaluation was to evaluate the uptake, return rate and new diagnosis rates of home-based testing in comparison with clinic-based testing for human immunodeficiency virus (HIV), syphilis (STS) and hepatitis B. Home-based testing, although popular, had low uptake amongst high-risk groups such as men who have sex with men (MSM), compared to the clinic-based group (1% versus 11%, p < 0.001). This resulted in low positivity rates for HIV (0.02%) and STS (0.17%) and no new cases of hepatitis B in the home-based group. Therefore, our results show that home-based testing is not a cost-effective method of testing for HIV and likely this is also the case for hepatitis B and STS. Our recommendation would be to encourage uptake of home-based testing in high-risk groups such as MSM and Black Africans to improve the diagnosis rates of HIV, STS and hepatitis B. Alternatively, the continuation of home-based blood testing in the Birmingham and Solihull area will need to be reviewed by Umbrella as a cost-saving strategy for the service in the future.

A service evaluation comparing home-based testing to clinic-based testing for Chlamydia and gonorrhoea in Birmingham and Solihull.

Home-based testing is an alternative, convenient and cost-effective method of testing for sexually transmitted infections compared to traditional clinic-based testing, in patients who are asymptomatic and, or, would otherwise feel stigmatised about attending sexual health clinics. The sexual health service in Birmingham and Solihull, called Umbrella, provides an online home-based testing service, which has been in operation since August 2015. The aim of this study was to evaluate the uptake and return rate of home-based testing kits and compare home-based testing to clinic-based testing in terms of diagnosis and treatment rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). Our study showed that home-based testing is a popular method of testing and relatively more popular amongst asymptomatic, young, heterosexual female and White patients than clinic-based testing, with a return rate of 48%. The diagnosis rates for CT/GC are comparable to patients who attend clinic for testing (8% vs. 10% in home-based and clinic-based groups, respectively, p < 0.001). The overall treatment rate was lower in the home-based compared to the clinic-based group (82% vs. 88%, p < 0.001). Umbrella will continue to provide this service within Birmingham and Solihull and aim to provide patients with alternative pathways for more convenient access to treatment.

Intravaginal boric acid: is it an alternative therapeutic option for vaginal trichomoniasis?

OBJECTIVES: Trichomoniasis, caused by Trichomonas vaginalis (TV), is the most common curable sexually transmitted infection worldwide. Current guidance in the UK is to treat TV with a nitroimidazole antibiotic. The high prevalence of TV, high rate of antibiotic resistance and limited tolerability to nitroimidazoles suggest that alternative treatment regimens are needed. Intravaginal boric acid (BA) has been used safely for the treatment of candida vulvovaginitis and bacterial vaginosis, and in vitro studies suggest BA is active against TV. We review the evidence for the efficacy of BA in patients with TV. METHODS: MEDLINE, EMBASE, CINAHL, AMED, HMIC and BNI and Grey literature databases, The Cochrane Library, Trial Registers, conference abstracts and proceedings were searched. Inclusion criteria were women aged 16 years or over with microbiological confirmation of TV infection and using BA as treatment. There were no restrictions on language, publication date or study design. The in vitro evidence for BA activity against TV was also reviewed. RESULTS: No randomised controlled trials or case series were found. Four case reports demonstrated TV clearance with BA using a variety of dose regimens (dose 600 mg alternate nights to 600 mg two times per day; duration 1-5 months). In vitro studies suggest that BA has activity against TV which is independent of its effect on pH. DISCUSSION: Further evaluation of BA for the treatment of uncomplicated TV is required, but it may be useful when therapeutic options are limited. If shown to be safe and effective, intravaginal BA might provide a well-tolerated alternative anti-infective treatment which reduces community exposure to systemic antibiotics.

Auditing the use and assessing the clinical utility of microscopy as a point-of-care test for Neisseria gonorrhoeae in a Sexual Health clinic.

We assessed whether urethral microscopy was performed as per clinic protocol for male clinic attendees reporting contact with Neisseria gonorrhoeae (GC), urethral symptoms or given a diagnosis of epididymo-orchitis (EO) over a 12-month period (9732 patients). Prevalence of gonorrhoea in the contacts, urethral symptoms and EO groups was 50, 12.7 and 1.6%, respectively. Microscopy was performed reliably for contacts (96%), those with discharge/dysuria with evidence of urethritis on examination (98%), but not those with EO (43%). We explored the clinical utility of microscopy as a point-of-care test for identifying urethral GC in each subgroup, using the APTIMA Combo 2 CT/GC nucleic acid amplification test as the comparator (1710 patients). Sensitivity of microscopy for each subgroup was good; there was no statistical difference between subgroup sensitivity using Fisher's exact test. Microscopy is valuable to ensure prompt diagnosis and contact tracing. All GC contacts were treated 'epidemiologically'; however, half of GC contacts did not have GC. Microscopy identified the majority of GC cases, including amongst contacts (71% of heterosexual contacts, 66% of contacts reporting sex with men). We propose that epidemiological treatment for GC contacts should be reconsidered on the grounds of antibiotic stewardship, favouring use of microscopy to guide treatment decisions.

The management of isolated positive syphilis enzyme immunoassay results in HIV-negative patients attending a sexual health clinic.

An unconfirmed positive treponemal enzyme immunoassay (enzyme immunoassay positive, Treponema pallidum particle agglutination negative and rapid plasma reagin negative) presents a clinical challenge to distinguish early syphilis infection from false-positive results. These cases are referred for syphilis line assay (INNO-LIA) and recalled for repeat syphilis serology. We performed a retrospective audit to establish the proportion of HIV-negative cases with unconfirmed positive enzyme immunoassay results, the proportion of these cases that received an INNO-LIA test and repeat syphilis serology testing and reviewed the clinical outcomes; 0.35% (80/22687) cases had an unconfirmed positive treponemal enzyme immunoassay result. Repeat syphilis serology was performed in 80% (64/80) cases, but no additional cases of syphilis were identified. Eighty-eight per cent (70/80) received an INNO-LIA test; 14% (5/37) unconfirmed enzyme immunoassay-positive cases with no prior history of syphilis were confirmed on INNO-LIA assay, supporting a diagnosis of latent syphilis. As a confirmatory treponemal test, the INNO-LIA assay may be more useful than repeat syphilis serological testing.

The performance and clinical utility of cervical microscopy for the diagnosis of gonorrhoea in women in the era of the NAAT.

We evaluated the performance and clinical utility of cervical microscopy for diagnosing genital gonorrhoea (GC) in women, using the APTIMA Combo 2 dual GC/Chlamydia trachomatis assay as the gold standard. Test performance was assessed overall and for patient subgroups (symptomatic, GC contacts, pelvic inflammatory disease [PID] diagnosis). It was found that 93 women had positive GC genital NAAT results; 15 had positive cervical microscopy (8 were GC contacts). In all subgroups except GC contacts, the PPV of cervical microscopy was below the nationally accepted target of 90%. Compared to APTIMA Combo 2, cervical microscopy has poor sensitivity for diagnosing GC in women (16.1% overall, 17.3% symptomatic, 25% GC contacts, 10.5% PID). GC contacts accounted for over 50% of the positive microscopy results and would have received epidemiological treatment for GC, regardless of the microscopy result. Discontinuing the routine use of cervical microscopy would improve patient flow through the sexual health clinic and resources could be utilised more effectively.

Screening for alcohol use disorders in a genitourinary medicine and contraception clinic: a service evaluation.

Summary National Institute for Health and Clinical Excellence guidance advises that all patients routinely undergo alcohol screening. Our service evaluation in a sexual health clinic assessed the acceptability of alcohol screening, the prevalence of hazardous drinking and the uptake of referral to a specialist alcohol service. Three services were evaluated: a genitourinary medicine service, a contraception service and an integrated sexual health service. AUDIT was used to screen 276 patients; those scoring ≥8 were classified as hazardous drinkers. Screening uptake was 58% overall, 58% for the contraception service, 71% for the genitourinary medicine service and 100% for the integrated sexual health service. Overall, 28% had AUDIT scores ≥8. Hazardous drinking rates were higher in the genitourinary medicine (32%) and integrated sexual health services (52%) compared to the contraception service (21%); 7% of hazardous drinkers accepted referral. High rates of hazardous drinking were identified within all three groups, but uptake of referral was low. Alternative strategies to specialist alcohol service referral are discussed.

Azidodeoxythymidine and didehydrodeoxythymidine as inhibitors and substrates of the human herpesvirus 8 thymidine kinase.

Human herpesvirus 8 (HHV-8), the aetiological agent of Kaposi's sarcoma (KS), encodes many core genes that have been maintained during evolution of the Herpesviridae. Among these is a thymidine kinase (TK) homologue (ORF21), which has 12% homology to the related TK encoded by herpes simplex virus. We show that the HHV-8 TK is a functional deoxythymidine (dT) kinase, with Michaelis constants (K(m)) for dT and ATP of 18.5 and 6.6 microM, respectively. Using homology modelling coupled with site-directed mutagenesis, we identify Gly265, Asp362 and Phe372 as key amino acid residues involved in the catalytic process. The HHV-8 TK is competitively inhibited by azidodeoxythymidine (zidovudine) and didehydrodeoxythymidine (stavudine) and can also accept these anti-retroviral compounds as substrates. These data have implications for our understanding of changes in AIDS-KS incidence following the clinical licensing of these compounds and in the development of new therapies for KS.