2nd BASHH Oxford Diagnostics Course,November 2015

The second British Association for Sexual Health and HIV (BASHH) Oxford Diagnostics Course was held on the 17th November 2015. These biennial meetings are designed to showcase innovation in diagnostics and service design. Speakers are given an opportunity to present evidence supporting changes in current practice. The audience is then invited to explore and challenge the proposals in an extended period of discussion. Six speakers gave presentations on a wide range of topics, from managing demand through service redesign to disruptive technologies and surviving a tendering process.

Dr John White opened with a provocatively entitled talk: Demand management in Sexual Health Clinics – Thinking outside the box.

The sexual health clinics at Guy’s & St Thomas’ Hospitals provide a full range of services to the population of Lambeth and beyond. The service has undergone tremendous reconfiguration. In his presentation, Dr White emphasised the need to reflect on the core needs for service in a cash-strapped health service. He reviewed recent service demands before making a series of suggestions to improve efficiency and cost-effectiveness.

He observed that in 2014, sexually transmitted infection (STI) numbers in England rose again, with young heterosexuals and men who have sex with men (MSM) being overrepresented. The largest increases were seen among MSM and this trend does not appear to be slowing. Increasing rates of STI diagnoses lead to an increase in the proportion of complex patients and contacts seen by clinics and this creates an additional drain on resources. He argued that to continue to provide open access to sexual health services and focus on groups at highest risk, busy clinics need to explore ways of freeing up capacity. He suggested possible ways to improve patient flow and reduce waiting times, which included effective triage and refinement of asymptomatic/symptomatic pathways, and matching each patient to an appropriate clinician. Eradication of slow processes and bottleneck situations within clinics might also be achieved by implementation of E-noting, E-prescribing/Patient Group Directions, E-order communications/sets for pathology tests and bar-coded stickers for specimens. In addition, the Burrell street clinic has recently adopted a ‘senior model’ with one senior doctor overseeing all clinics across the service. An analysis of the service before and after this change indicated that such a model supports the entire team to see more patients in total. Dr White also spoke about the need to look carefully at the costs of supporting pathology services and that omitting unnecessary tests will not only save money but staff time. He suggested a range of strategies that might help achieve this (depending on local factors): these could include cessation of practices that are shown to have little or no value, such as unnecessary tests of cure, post-exposure prophylaxis toxicity monitoring and screening outside of populations at risk. Early work on intrapatient pooling strategies for gonorrhoea and chlamydia testing suggests that this might be cost-effective for both MSM and women. Clinic flow and antibiotic stewardship may also be improved if the traditional practice of treating all sexual contacts can be rationalised in an era of superior assays with high negative predictive values. Such changes in practice might be controversial, but given that the National Health Service (NHS) financial pot for sexual health is shrinking in real terms and demand is rising, more evidence is needed to support practices that are time-consuming, expensive and add limited value.

Dr Anatole S Menon-Johansson, also from Guy’s & St Thomas’, presented: Remote testing for STIs – Is it practical and is it needed? He reviewed the social enterprise SH:24 (www.sh24.org.uk). This novel service was one of the first to offer NHS-based online testing for STIs and had been developed using a design-led agile approach. The audience was taken through the patient journey and data were presented showing the growing adoption over time, the demographics of users and the key performance indicators. The key metrics were that over 6500 patients had used the service, the test-kit return rate was 72%, all users had 24-h delivery, and for 95% the turnaround time for results was three days. One in five users had never been to an STI clinic previously and 86% of first-time users accepted a HIV test. MSM, black/ethnic minority patients and young people (under 25 years of age) using the service constituted 15%, 11% and 32%, respectively. The presentation concluded with data from another social enterprise SXT (www.sxt.org.uk), with 4040 users within a 50 km radius of central London since the beginning of 2015. A total of 353 different providers were selected by clients looking for sexual and reproductive health (SRH) services and the top three provider groups: SRH clinics, primary care and online services were selected by 58%, 28% and 7%, respectively. SXT supports providers to improve access to SRH healthcare. Finally, it was announced that SXT was the recipient of the Public Health England HIV Prevention Innovation Fund for a new partner notification tool that was subsequently launched on World AIDS day (www.sxt.org.uk/pn/about).

Professor Jonathan Ross of University Hospitals Birmingham reviewed the case for novel nucleic acid amplification tests (NAATs) in his presentation: Nucleic Acid Amplification Tests for Trichomonas Vaginalis – Implications for screening and testing. He reviewed the epidemiology of Trichomonas vaginalis (TV) and explained that it causes 6000 infections in patients attending STI clinics in England each year. Infection rates are higher in urban areas and vary globally, with particularly high rates reported among prison populations in the USA. At least two different subtypes of Trichomonas can be differentiated by their clinical features. Type 1 is identified more readily on wet mount microscopy and is more sensitive to antibiotic therapy when compared to type 2.

Testing for TV with microscopy and culture is relatively insensitive: within 30 minutes, over a third of protozoa will no longer show motility on wet mount microscopy. Two commercial platforms are now available for nucleic acid testing: the Becton Dickinson and Gen-Probe/Hologic assays. NAATs show sensitivity of over 98% compared to 66% for microscopy and 90% for culture in women. Using NAATs, the prevalence of TV in patients attending STI clinics is 1–3%, although rates among women are two to three times higher than those in men. Particularly high rates are found in subgroups of the population, e.g. Black Caribbean women in Birmingham have a 9% rate of infection. Using TV NAATs will pick up an additional 40% of infections compared to microscopy or an additional 25% compared to culture. However, this has to be offset against the higher cost of NAATs (£3–4 compared to £1 for culture).

Professor Ross concluded that the use of TV NAATs is appropriate in symptomatic women, the male partners of women with TV, and in men with persistent urethritis. Consideration should also be given to screening high-risk groups where the prevalence of infection is over 5%.

Two speakers, Dr Aura Andreasen and Dr Syed Tariq Sadiq, spoke on the importance of diagnostics in managing the spread of antimicrobial resistance (AMR).

Dr Andreasen of Health Protection England focussed on emerging AMR at both global and national levels. She made the case for maintaining vigilance and the need to ensure that future services are commissioned in order to track antimicrobial sensitivity.

Dr Sadiq of the e-STI collaboration spoke on the subject of disruptive technologies and how they may add value to sexual health services.

In his presentation, he noted that curable STIs, such as gonorrhoea, syphilis, chlamydia, TV and Mycoplasma genitalium, present a serious global health challenge. Recent systematic appraisals of evidence suggest that M. genitalium is a serious cause of reproductive health disease in women. Both gonorrhoea and M. genitalium infections are further compromised by high rates of AMR to multiple antibiotic classes, threatening simplified empirical therapy. Genotypic markers of antibiotic resistance to macrolides in M. genitalium and to fluoroquinolones in gonorrhoea are all well-defined. Dr Sadiq’s research team have shown that use of simple genotypic testing for fluoroquinolone resistance in gonorrhoea detected at genital and extra-genital anatomical sites is highly effective in predicting ciprofloxacin susceptibility. Such an approach is likely to achieve cure more often than relying on national epidemiological patterns and will achieve levels of cure achieved by first-line choice of antibiotic, beyond the threshold advised by the WHO. These developments allow for novel point-of-care (POC) AMR technologies to enhance empirical antibiotic therapy for genital discharge syndromes, enabling recycling of previously discarded antibiotics and potentially reducing spread of AMR. Novel molecular POC technologies, both hand-held and desktop-based for pathogen detection, will soon be available for use in UK clinics. The National Institute for Health Research funded Precise Project (www.preciseresearch.co.uk) is developing POC AMR tools for sexual health. The extended use of such technologies will help manage patients with genital discharge syndrome for whom empirical antibiotic selection has become increasingly challenging. The work is informed by public patient involvement at an early stage in design.

The meeting closed with a presentation by Dr Jackie Sherrard: Personal reflections on the tendering process. Dr Sherrard’s own unit in Oxford has recently undergone a tendering process and she gave a detailed and frank account of the time and energy needed to support a bid. She explained the efforts required for a successful outcome and the importance of establishing early and close links to key individuals in the new health economies. These would in future need to include key individuals in local council wards and Public Health representatives. Over the last two years, Dr Sherrard has been one of a small number of BASHH consultants nominated to advise commissioners on service specifications for Genito-Urinary Medicine prior to tendering. Dr Sherrard explained that when a tendering process was likely, encouraging commissioners to take early external expert advice on service specifications and process resulted in better quality outcomes. Her presentation concluded with important advice on how to rebuild relationships and services after a competitive tendering process, when members of an extended clinical team may have been forced to compete and develop rival models for service redesign.