Screening for chlamydia and/or gonorrhea in primary health care: systematic reviews on effectiveness and patient preferences

Abstract

Background We conducted systematic reviews on the benefits and harms of screening compared with no screening or alternative screening approaches for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in non-pregnant sexually active individuals, and on the relative importance patients’ place on the relevant outcomes. Findings will inform recommendations by the Canadian Task Force on Preventive Health Care. Methods We searched five databases (to January 24, 2020), trial registries, conference proceedings, and reference lists for English and French literature published since 1996. Screening, study selection, and risk of bias assessments were independently undertaken by two reviewers, with consensus for final decisions. Data extraction was conducted by one reviewer and checked by another for accuracy and completeness. Meta-analysis was conducted where appropriate. We used the GRADE approach to rate the certainty of the evidence. The Task Force and content experts provided input on determining thresholds for important effect sizes and on interpretation of findings. Results Of 41 included studies, 17 and 11 reported on benefits and harms of screening, respectively, and 14 reported on patient preferences. Universal screening for CT in general populations 16 to 29 years of age, using population-based or opportunistic approaches achieving low screening rates, may make little-to-no difference for a female’s risk of pelvic inflammatory disease (PID) (2 RCTs, n=141,362; 0.3 more in 1000 [7.6 fewer to 11 more]) or ectopic pregnancy (1 RCT, n=15,459; 0.20 more per 1000 [2.2 fewer to 3.9 more]). It may also not make a difference for CT transmission (3 RCTs, n=41,709; 3 fewer per 1000 [11.5 fewer to 6.9 more]). However, benefits may be achieved for reducing PID if screening rates are increased (2 trials, n=30,652; 5.7 fewer per 1000 [10.8 fewer to 1.1 more]), and for reducing CT and NG transmission when intensely screening high-prevalence female populations (2 trials, n=6127; 34.3 fewer per 1000 [4 to 58 fewer]; NNS 29 [17 to 250]). Evidence on infertility in females from CT screening and on transmission of NG in males and both sexes from screening for CT and NG is very uncertain. No evidence was found for cervicitis, chronic pelvic pain, or infertility in males from CT screening, or on any clinical outcomes from NG screening. Undergoing screening, or having a diagnosis of CT, may cause a small-to-moderate number of people to experience some degree of harm, mainly due to feelings of stigmatization and anxiety about future infertility risk. The number of individuals affected in the entire screening-eligible population is likely smaller. Screening may make little-to-no difference for general anxiety, self-esteem, or relationship break-up. Evidence on transmission from studies comparing home versus clinic screening is very uncertain. Four studies on patient preferences found that although utility values for the different consequences of CT and NG infections are probably quite similar, when considering the duration of the health state experiences, infertility and chronic pelvic pain are probably valued much more than PID, ectopic pregnancy, and cervicitis. How patients weigh the potential benefits versus harms of screening is very uncertain (1 survey, 10 qualitative studies); risks to reproductive health and transmission appear to be more important than the (often transient) psychosocial harms. Discussion Most of the evidence on screening for CT and/or NG offers low or very low certainty about the benefits and harms. Indirectness from use of comparison groups receiving some screening, incomplete outcome ascertainment, and use of outreach settings was a major contributor to uncertainty. Patient preferences indicate that the potential benefits from screening appear to outweigh the possible harms. Direct evidence about which screening strategies and intervals to use, which age to start and stop screening, and whether screening males in addition to females is necessary to prevent clinical outcomes is scarce, and further research in these areas would be informative. Apart from the evidence in this review, information on factors related to equity, acceptability, implementation, cost/resources, and feasibility will support recommendations made by the Task Force. Systematic review registration International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018100733.

Controversies and evidence on Chlamydia testing and treatment in asymptomatic women and men who have sex with men: a narrative review

“…Targeted testing involves offering tests to key populations such as high-risk young women, sex workers, or MSM; for example, in general practice or ‘high-risk settings’ such as emergency departments, homeless shelters, and STI or HIV clinics. A meta-analysis reported that community-based testing in general populations may make little-to-no difference for CT transmission and a woman’s risk of PID or EP; evidence on infertility was very uncertain, and no evidence was found for cervicitis or chronic pelvic pain [ 4 ]. Previous studies suggest that screening can reduce PID risk at the individual level [ 40 , 62 ].…”

“…Previous studies suggest that screening can reduce PID risk at the individual level [ 40 , 62 ]. The meta-analysis concluded that benefits might potentially be achieved for reducing CT transmission and PID by targeted and intense (repeat) testing of high-prevalence key female populations [ 4 ]. Postulated reasons why test-and-treat strategies might not reduce prevalence in 'real-life' include—alongside low test uptake—that treated patients have lower protective immunity [ 63 ], but reasons for the gap between models and practice remain largely unclear.…”

“…A meta-analysis reported that undergoing testing or having a diagnosis of CT may cause a small-to-moderate number of people to experience some degree of harm (feelings of stigmatization, anxiety about future infertility, intimate partner violence), with most studies in women [ 4 , 68 , 69 ]. How patients weigh the potential benefits versus the harm of screening was found to be uncertain in this meta-analysis, yet risks to reproductive health (infertility, chronic pelvic pain) and transmission appear to be more important than the (often transient) psychosocial harm involved [ 4 ]. However, it is unknown to what extent women over- (or under-) estimated the actual CT complication risks.…”

“…The initial infection is often asymptomatic but might include vaginal discharge [ 3 ]; asymptomatic infection is only revealed by active testing. If left untreated, infection can result in pelvic inflammatory disease (PID), ectopic pregnancy (EP), and tubal infertility (TFI) in women [ 4 , 5 ]. CT can be reliably tested on self-collected samples using nucleic acid amplification tests (NAATs) and is treated with azithromycin (1 g orally) as a single dose, or with doxycycline (100 mg orally twice a day for seven days), depending on the anatomic site of infection and local STI guidelines.…”

A Participatory Design Approach to Develop Visualization of Wearable Actigraphy Data for Health Care Professionals: Case Study in Qatar

“…The use of opportunistic research and sampling is commonly used in health care research as it allows researchers to use the available participants or research instruments to perform research chores [ 45 - 49 ]. To the best of our knowledge, there is no interactive tool that has considered the needs of local health care professionals in Qatar in their regular activities.…”