Sexually Transmitted Diseases:
The Efficacy of Clinic-Based Interventions Aimed at Increasing Screening for Bacterial Sexually Transmitted Infections Among Men Who Have Sex With Men: A Systematic Review
Zou, Huachun MD, MS*; Fairley, Christopher K. FRACP, PhD*,†; Guy, Rebecca PhD‡; Chen, Marcus Y. FAChSHM, PhD*,†
From the *Sexual Health Unit, School of Population Health, University of Melbourne, Melbourne, VIC, Australia; †Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia; and ‡Kirby Institute, University of New South Wales, Sydney, NSW, Australia
The authors thank Chris Bourne and Anna Hotton for providing detailed information of the interventions.
Correspondence: Marcus Chen, FAChSHM, PhD, Melbourne Sexual Health Centre, 580 Swanston St, Carlton, VIC 3053, Australia. E-mail: firstname.lastname@example.org.
Received for publication October 27, 2011, and accepted December 20, 2011.
Background: In many countries, the prevalence of bacterial sexually transmitted infections (STIs) among men who have sex with men (MSM) is high. We undertook a systematic review to identify clinic-based strategies for increasing screening and detection of bacterial STIs among MSM.
Methods: We reviewed studies that compared screening for or detection of gonorrhea, chlamydia, and syphilis in the presence and the absence of an intervention. The primary end points were STI screening, rescreening, or detection rates.
Results: Of 1809 studies identified, 8 fulfilled the inclusion criteria; of these, 4 studies demonstrated significant increases in screening rates for gonorrhea and chlamydia using different strategies (odds ratio range, 1.4–1.9). These included the following: use of a computer alert on an electronic medical record; the introduction of clinic guidelines on STI screening; and short text messaging reminders for repeat STI screening. A further 4 studies demonstrated increases in syphilis testing (odds ratio range, 2.3–21.4), with increased detection of asymptomatic early syphilis in 2 studies. Strategies used included regular serological screening for syphilis during routine human immunodeficiency virus (HIV) care, syphilis serology included with blood tests performed as part of HIV monitoring, use of a computer alert on an electronic medical record, and an electronic medical record system to enhance syphilis retesting after syphilis treatment.
Conclusions: A range of interventions has been used, including the application of newer technologies targeting clinicians and patients that appear to be efficacious at increasing screening of MSM for bacterial STIs. Wider application of such interventions could improve STI screening and control in this high-risk population.
In many countries, the prevalence of bacterial sexually transmissible infections (STIs) such as gonorrhea, chlamydia, and syphilis is high among men who have sex with men (MSM).1–4 STIs in MSM are of particular public health importance because of their potential to increase human immunodeficiency virus (HIV) transmission. Recent studies have demonstrated associations between chlamydia, gonorrhea, and syphilis infection and HIV seroconversion.5,6
More frequent screening for bacterial STIs has the potential to improve detection of these largely asymptomatic infections, interrupting transmission and improving control. For HIV-infected men, the detection and treatment of other STIs could potentially reduce onward transmission of HIV. Guidelines in a number of countries call for regular screening of MSM. For example, US and Australian guidelines recommend that all MSM be screened for urethral and rectal chlamydia, pharyngeal and rectal gonorrhea, syphilis, and HIV at least once a year, with 3 to 6 monthly screening of higher-risk MSM.7,8 However, available data suggest that the rate of screening for these infections among MSM is low in many countries.9–12 Barriers to clinicians performing and men undertaking screening for STIs have been identified and include clinicians' lack of awareness and skills to undertake STI screening, as well as perceptions among some MSM that STIs are less serious than HIV.13,14
To help inform strategies that clinical services can use to help increase STI screening of MSM, we undertook a systematic review to identify clinic-based interventions efficacious at increasing screening and detection of gonorrhea, chlamydia, and syphilis among MSM.
We conducted a systematic review by searching MEDLINE for studies between 1990 and June 2011 using the following key words and variations: “men who have sex with men” or “MSM” or “gay” or “homosexual” or “bisexual”; and “syphilis” or “chlamydia” or “gonorrhea” or “gonorrhoea” or “sexually transmitted disease” or “STD” or “sexually transmitted infection” or “STI”. Only English language publications were included. Reference lists of selected studies were also checked for other potentially relevant studies.
A publication was considered for inclusion if it reported on the evaluation of a clinic-based intervention aimed at increasing bacterial STI screening rates (proportion of men screened); rescreening rates (proportion of men screened again); or detection rates (proportion of men tested diagnosed with an infection) in MSM, and if it included a control group or control period.
Studies were excluded if they did not include a control group or control period; reported screening rates in the absence of a specific intervention; involved STI screening outside of clinics such as outreach services and online testing services; focused on partner notification for STIs; or were studies designed to increase the sensitivity of laboratory testing methods in MSM populations, for example, studies comparing the use of nucleic acid amplification testing with culture.
For each study that met the inclusion criteria, information was extracted on the study setting, target population, study design, nature of the intervention, comparison periods, outcomes, sample size, and statistical methods used. We also calculated crude odds ratios (ORs) based on data from the studies where these were available in the published paper.
We conducted a frequency analysis of information related to the clinic (location, type), intervention type, and evaluation methods (sample size, design, period of the evaluation, and reported outcomes).
The primary outcome for each study was the screening rate, rescreening rate, and/or detection rate for individual STIs where data on individual STIs were provided. Otherwise, we cite summary figures with more than 1 STI included.
For each study, we abstracted the OR indicating the proportion tested in the intervention group compared with controls. For studies that did not provide an OR, we calculated the OR using STATA 11 (StataCorp, College Station, TX), including 95% confidence intervals, if the necessary figures were provided in the paper.
Overview of Studies and Interventions
The results of the search are summarized in Figure 1. We identified 1809 papers, with 8 satisfying the inclusion criteria.13,15–21 The studies with the effects of their various interventions are summarized in Table 1. The studies were conducted in Australia (n = 6), the United States (n = 1), and the United Kingdom (n = 1). Six studies reported screening rates as a primary outcome,13,15,17,19–21 with an additional study focused on rescreening.17 A further study examined serological follow-up for syphilis after syphilis treatment.16 This study was included because of the potential for repeat serology to identify reinfections with syphilis. Three studies reported screening data on all 3 STIs (gonorrhea, chlamydia, and syphilis),13,18,19 1 reported on gonorrhea and chlamydia only,15 and 4 reported on syphilis only.16,17,20,21 In 2 studies, infections were described by anatomical site.13,15
All studies reported using a retrospective, observational design with a control period. One study also used a concurrent comparison group,18 and the remaining 7 a historical comparison group. Three studies included HIV-positive men only,17,19,20 1 included HIV-negative men only,18 and 4 included both HIV-positive and HIV-negative men.
Four studies aimed at increasing screening for gonorrhea and chlamydia, with or without syphilis (Table 1).13,15,18,19 A further 4 studies focused on syphilis screening, detection, or serological follow-up (Table 2).16,17,20,21 Four studies evaluated the use of interventions that used newer technologies.15,16,18,21 Hotton et al16 evaluated the use of an electronic medical record system in a US primary care clinic to enhance serological follow-up after treatment for syphilis. In this intervention, all clinical, laboratory, and diagnostic data were stored electronically in the electronic record. The record allowed disease intervention specialists to generate reminders for themselves to contact patients for follow-up syphilis screening. Specialists created a flag at the time of diagnosis or treatment, which triggered a reminder message in the record for the specialist to contact patients so they would return to the clinic for retesting. Lister et al15 examined the use of a computer alert on an electronic medical record to remind clinicians in an STI clinic to screen for gonorrhea and chlamydia during clinical consultations. The clinic routinely collected clinical information on a computerized system during consultations, which included history of sex partners in the prior 12 months. If a male client had 1 or more male sex partners in the previous 12 months, this clinical information triggered the computer reminder during a clinical consultation. In the same STI clinic, Bissessor et al21 assessed the effect of a computer alert on an electronic medical record to remind clinicians to undertake 3-monthly syphilis testing of MSM with ≥10 male partners in the prior 12 months. Here, entry of ≥10 male partners triggered an alert to screen higher-risk MSM for syphilis 3-monthly during the consultation. In a study by Bourne et al,18 SMS (short text messaging) reminders for repeat STI screening were sent to men after an initial consultation at an STI clinic. In this intervention, an SMS reminder template was added to the patient electronic database and clinicians were encouraged to offer SMS reminders for 3- to 6-monthly HIV/STI retesting to MSM tailored to their level of risk.
In 4 other studies, STI screening was linked to other clinical activities with the aim of boosting STI testing. Cohen et al17 examined the effect of regular serological screening for syphilis during routine HIV care with the aim of detecting asymptomatic syphilis infections. Bissessor et al20 determined the impact of including syphilis serology with blood tests performed as part of routine HIV monitoring. By default, a request for syphilis serology was automatically included on all pathology request forms used in the HIV clinic for the monitoring of HIV-positive patients. Ryder et al13 assessed the impact of the introduction of clinic guidelines recommending at least annual STI screening of MSM in an STI clinic. Botes et al19 examined the effect of including STI screening with anal cytologic screening. In this intervention, STI testing was offered to MSM taking part in an anal cytologic screening program.
Impact of Interventions
Increases in screening, rescreening, or detection of selected bacterial STIs were seen in all 8 studies (Tables 1 and 2). In the evaluation by Hotton et al, use of an electronic medical record reminder to specialists improved syphilis retesting rates at 6 months from 64% to 81% (P = 0.047).16 Lister et al found that a computer alert on an electronic medical record that reminded doctors to screen MSM for gonorrhea and chlamydia during consultations significantly increased screening for these 2 infections from 78% to 83% (P = 0.023).15 In the study by Bissessor et al, use of a computer alert on an electronic medical record that reminded clinicians during consultations to undertake 3-monthly syphilis testing of higher-risk MSM increased the proportion of high-risk MSM screened for syphilis from 77% to 89% (P < 0.001) and the proportion of early syphilis detected that was asymptomatic from 16% to 53% (P < 0.001).21 Bourne et al found that an SMS reminder for repeat STI screening after an STI consultation increased rescreening from 31% (P < 0.001) in the pre-intervention group and 30% (P < 0.001) in the concurrent comparison group to 64% in the intervention group.18
In their study, Cohen et al demonstrated that regular serological screening for syphilis during routine HIV care increased the proportion of HIV-positive individuals screened for syphilis from 3% to 85% (P value not available).17 In the study by Bissessor et al, where syphilis serology was included with blood tests performed as part of routine HIV monitoring, there was an increase in the median number of syphilis tests performed in the prior 12 months from 1 to 2 and an increase in the proportion of early syphilis detected that was asymptomatic (21%–85%, P < 0.001). There was also a significant decrease in the median time between the midpoint since last syphilis serology and detection: from 107 to 45 days (P = 0.018).20 Ryder et al found that the introduction of clinic guidelines recommending at least annual STI screening of MSM increased screening for gonorrhea, chlamydia, and syphilis from 43% to 61% (P < 0.001).13 In the study by Botes et al, screening for gonorrhea, chlamydia, and syphilis increased from 20% to 35% (P < 0.001) when STI screening was undertaken with anal cytologic screening.19
To our knowledge, this is the first systematic review of clinic-based interventions aimed at increasing the screening and detection of bacterial STIs among MSM. Although there are many published studies of STI prevalence among MSM, there are few data measuring STI screening rates in MSM, and even fewer studies that have specifically assessed the efficacy of clinic-based strategies aimed at improving STI screening in this population. Of the small number of studies that were identified, which used a range of intervention, all demonstrated an increase in screening rates for selected bacterial STIs including gonorrhea and chlamydia, with 2 studies showing increased detection of asymptomatic, early syphilis.17,20,21
There are limitations to this review and to the studies included. First, and perhaps the most important, all studies discussed in this review compared data before and after an intervention: none were randomized controlled trials. Therefore, it is difficult to know whether the increases in screening and/or detection rates seen were entirely a result of the interventions or to some extent a result of other unmeasured factors. Second, we did not search the gray literature such as conference abstracts; thus, it is possible that some evaluations were not identified, particularly those with negative outcomes. Third, the extent to which the specific interventions would be effective in different populations of MSM and different clinical services is unknown. Owing to the heterogeneity of the interventions and the various outcomes, we were unable to pool the outcomes to determine a summary effect. Nevertheless, most of the studies were conducted in specialist sexually transmitted disease or HIV clinics where awareness of and screening rates for STIs were presumably already high; yet, further improvements in screening were seen. In clinical settings where awareness among health care providers and STI screening rates among MSM is low, the potential for greater impact with the various measures used would presumably be even greater.
Although the strategies aimed at improving STI screening among MSM varied substantially, several included the application of newer technologies such as the use of electronic medical record systems that incorporated alerts for clinicians during consultations or reminders for clinicians to undertake subsequent retesting. In 1 study, the alert resulted in a more comprehensive range of tests being undertaken, with chlamydia and gonorrhea screening of all recommended anatomical sites (rectal, pharyngeal, and urine) increasing from 41% to 83%.15 Computer alerts have also been shown to improve HIV screening in Veteran Affairs clinics in the United States,22 chlamydia screening rates among young women attending Australian general practice clinics, and practice in other disciplines such as measurement of blood pressure,23 vaccination,24–26 and prescription of medications.27 In addition to the use of alerts and reminders, electronic medical record systems that include electronic ordering of laboratory tests allow predefined sets of tests to be ordered together by default. This would potentially increase completeness of testing, for example, to ensure pharyngeal, urine, anal, and serological specimens are taken concurrently, and linkage of STI testing with other clinical activities, such as HIV monitoring of HIV-positive MSM. Once established, such electronic alerts, reminders, and links require minimal staffing or ongoing costs.
In one of the studies included in this review, SMS messages increased rescreening for STIs. SMS reminders are relatively cheap, and the acceptability of SMS reminders has been demonstrated in the sexual health context.28,29 SMS or e-mail reminders for STI screening can be offered and automatically sent to patients attending STI clinics through routine clinical use of computer-assisted self-interview. Furthermore, in settings where laboratory results are incorporated into the electronic record, SMS reminders to patients for repeat STI testing could be sent automatically after receipt of an initially positive laboratory result.
Overall, the results of the studies included in this review suggest that screening for and detection of bacterial STIs in MSM can be improved in clinical settings using a range of approaches. Some of the interventions identified in this review would have modest operating costs and require limited staffing to maintain once established.18 Wider adoption of these interventions and the development of innovative interventions appear to be warranted. Future randomized studies should examine the use of multifaceted approaches that combine several different interventions including the application of new technologies.
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