Trichomoniasis is the most prevalent nonviral sexually transmitted disease in the United States affecting an estimated 3.7 million individuals.1 It is caused by infection with the protozoa Trichomonas vaginalis, and can present with vaginitis in women and urethritis, epididymitis, or prostatitis in men. Although most infected individuals are asymptomatic or minimally symptomatic,2 trichomoniasis is associated with other concurrent sexually transmitted infections (STIs), such as herpes simplex virus and human immunodeficiency virus (HIV),3,4 adverse pregnancy outcomes including preterm birth,5 and pelvic inflammatory disease in women infected with HIV.6 In light of its high prevalence, asymptomatic presentation, and association with other STIs and with pregnancy complications, appropriate screening and treatment of trichomoniasis may be of public health importance. Recent Centers for Disease Control and Prevention (CDC) recommendations published in 20157 are to screen asymptomatic women with HIV and test for T. vaginalis infection in women seeking care for vaginal discharge. Recommended treatment is oral metronidazole or tinidazole 2 g as a single dose. Metronidazole 500 mg twice daily for 7 days is the alternative treatment, which is also recommended in treatment failure or those with HIV coinfection. Sex partners should also undergo concurrent treatment.
There are limited studies evaluating the knowledge, attitudes, and practices (KAP) relating to screening, diagnosis, and treatment of trichomoniasis by health care providers in the United States. These have focused on screening. Eighty-nine percent of prenatal care providers in Georgia reported screening symptomatic pregnant women for trichomoniasis.8 Similarly, analysis of data from a network of sexually transmitted disease clinics in the United States found that most clinics tested symptomatic women (≥89%); however, only 44% of women infected with HIV were tested or screened for trichomoniasis.9 Nevertheless, recent availability of nucleic acid amplification testing (NAAT) appears to have increased the rate of testing for trichomoniasis in a group of clinics in a metropolitan area.10 To better understand provider KAP relating to trichomoniasis, the American College of Obstetricians and Gynecologists (ACOG) conducted a survey of its members in 2016. Here, we report results identifying discrepancies in optimal screening and management.
MATERIALS AND METHODS
Study Design and Participants
In October 2016, 1000 members of the ACOG were emailed personalized links to the survey along with information for informed participation through the survey-platform Qualtrics (Qualtrics, Provo, UT). Clicking on the link and answering survey questions was taken as implied physician consent to participate in the study. Of 1000 members, 500 were a randomly selected cohort of members in the Collaborative Ambulatory Research Network (CARN). The CARN was created to investigate the practice of obstetrics and gynecology in the outpatient setting.11 The CARN members are ACOG members who volunteer to participate in survey studies several times a year; they have been found to be representative of ACOG members by gender ratio, age, and geographic location.11 To prevent overcontact of CARN members from small districts, no stratification by district was performed in the random sampling. The other 500 ACOG members were non-CARN members randomly selected and stratified by nonmilitary ACOG districts, with sample sizes reflecting the proportionate size of each district. Developed at ACOG in consultation with the CDC, the survey assessed providers' screening practices, understanding of diagnosis and treatment, attitudes, and education/training related to trichomoniasis in 17 content-based questions (Tables 2, 3, 4, and 6). Nine demographic questions were also asked in the survey (Table 1). Survey recipients who had yet to take the survey or opt-out within 1- to 2-week intervals were sent reminders through Qualtrics. Up to 5 reminders per recipient were sent before data collection closed in December 2016.
This survey was approved as a nonresearch program evaluation activity by the Office of the Associate Director for Science, Center for Global Health at CDC and was determined to be exempt from review by the institutional review board of ACOG. No patient data were collected.
Data were analyzed using R statistical software.12 Incomplete surveys were defined as those having less than 3 content-based survey questions answered for each respondent and were excluded from analysis. To determine the degree of correlation between the respondent population and the overall ACOG membership by available demographic features of sex, state, and ACOG membership district, we performed χ2 testing by these features using membership data from January 5, 2017. For survey responses, we calculated proportions of individuals choosing each response in each question and calculated 95% confidence intervals (95% CI) using the Clopper-Pearson method. We also calculated proportions separately for CARN and non-CARN groups, and compared them using Fisher’s exact test. For questions where responses were discrepant from standard practice (denoted by the dagger, †, in the relevant tables), we performed multiple logistic regression to analyze associations between these responses and respondent demographic characteristics. Here, the respondent's years in practice postresidency, number of patients seen, and frequency of testing or treating for trichomonas a month were treated as a continuous covariates, whereas other demographic features (gender, ethnicity, primary practice, current practice type, and practice location) were treated as categorical factors. Respondent age was not included in the logistic regression given collinearity with the number of years in practice postresidency. Tests were considered statistically significant for a P less than 0.05. Multiple-comparison corrections were not made.
Survey Response Rate
Of 500 CARN members randomly selected, 470 received electronic surveys (21 opted out, and 9 had undeliverable email addresses), to which 32.6% responded. Of the 500 non-CARN members selected, 487 received electronic surveys (5 opted out, 8 had undeliverable email addresses), to which 16.8% responded. Overall, of the 957 members who received a survey, 235 (24.6%) responded. Five respondents with incomplete surveys were excluded, and the 230 surveys from the remaining respondents were used in subsequent analysis.
The mean age of respondents was 51.2 years (95% CI, 49.8%–52.7%), with a mean of 19.3 years (95% CI, 17.8–20.8) in practice postresidency. The majority of respondents were female (63.3%; 95% CI, 56.3–69.9), of white race/ethnicity (79.4%; 95% CI, 73.2%–84.7%), primarily practicing in general obstetrics and gynecology (71.3%; 95% CI, 64.6%–77.3%). A plurality of respondents had a current practice in an obstetrician-gynecologist (ob-gyn) partnership/group (38.3%; 95% CI, 31.7%–45.2%) and practiced in a suburban location (31.9; 95% CI, 25.6%–38.7%). These responses, constituting at least a plurality of all possible responses, were used as the reference levels for factors in subsequent logistic regression.
There were no significant differences in demographic features between CARN and non-CARN members except by primary practice, the number of times testing for trichomoniasis, or number of patients seen in a typical month (P < 0.05, <0.05, and < 0.01 by Fisher exact test, respectively; Table 1). When comparing all respondents with the ACOG membership by demographic characteristics of gender, state, and ACOG district, there was a significant difference by gender (χ2 = 4.8, df = 1, P = 0.03; 36.7% male among respondents, 44.5% male in ACOG membership), but not by state or ACOG district (χ2 = 64.0, df = 78, P = 0.87 and χ2 = 7.5, df = 10, P = 0.68, respectively).
Questions assessing provider knowledge of trichomoniasis found that the majority of respondents recognize that trichomoniasis increases the risk of HIV acquisition (67.0% at least somewhat agreeing), is often asymptomatic (70.0% at least somewhat agreeing) and increases the risk of adverse pregnancy outcomes (57.6% at least somewhat agreeing). Most respondents recognized that treatments for trichomoniasis are not known to cause adverse pregnancy outcomes13 (53.3% disagreed that treatment causes adverse pregnancy outcomes) and felt that treatment should not be deferred in pregnant women (77.8% disagreed treatment should be deferred). Finally, 40.2% (95% CI, 33.6%–47.1%) of the respondents reported receiving continuing education that includes information on the diagnosis and management of T. vaginalis, and 84.5% (95% CI, 78.9%–89.1%) see a benefit from additional training or resources regarding the diagnosis and management of T. vaginalis (Table 2).
The majority of respondents agreed that costs of universal screening (testing all women who present for care) would outweigh any potential benefits (58.2% at least somewhat agreeing), and the majority of respondents disagreed that asymptomatic women should be routinely screened for trichomoniasis (72.6% at least somewhat disagreeing), or that trichomoniasis is a significant health issue in their practices (58.2% at least somewhat disagreeing) (Table 3).
With respect to questions on the diagnosis of trichomoniasis, 91.7% (95% CI, 87.3%–94.9%) of the respondents reported screening (of asymptomatic patients) or testing of symptomatic patients. Wet mount was used by most respondents to diagnose trichomoniasis (77.1%; 95% CI, 70.9%–82.6% of respondents). The majority of respondents (64.3%; 95% CI, 57.1%–71.0%) correctly identified NAAT tests as having the best accuracy for detecting trichomoniasis. In accordance with CDC screening recommendations,14 83.4% of respondents reported performing testing “most of the time” or “always” if patients presented with vaginal discharge, whereas only 43.7% performed testing if patients presented with HIV infection. More than half of respondents tested “most of the time” or “always” when patients presented with another STI (69.5%), vulva itchiness (53.1%), strawberry cervix (85.3%), inflammation of the cervix, vagina, and/or urethra (73.3%), or pelvic inflammatory disease (71.3%). Half or less of respondents tested “most of the time” or “always” for trichomoniasis when patients presented with vulvar irritation (50.0%), pain with urination (19.0%), pain during sexual intercourse (29.4%), being sexually active and asymptomatic (7.7%), or pregnancy (17.3%) (Table 4).
For patients diagnosed with trichomoniasis, a majority of respondents recommended screening for other STIs (95.3%; 95% CI, 91.5%–97.7%) and HIV (55.5%; 95% CI, 48.5%–62.3%) (Table 4).
Given the CDC recommendation for screening for trichomoniasis in HIV-positive populations at entry into care and then at least annually,14 we evaluated key demographic characteristics that may influence screening in this subpopulation. We found the number of times a respondent tested for trichomoniasis in a typical month (odds ratio [OR], 1.03; 95% CI, 1.01–1.05) and being in a solo private practice (OR, 5.18; 95% CI, 1.37–19.66 vs. being in an ob-gyn partnership/group) was associated with screening HIV-positive women “most of the time” or “always” (Table 5).
The majority of respondents preferred treatment with one dose of metronidazole 2 g for nonpregnant, non–HIV-positive patients (76.0%; 95% CI, 69.8%–81.6%) and pregnant patients (55.6%; 95% CI, 48.7%–62.3%). Notably, a plurality of respondents preferred the same dosing for HIV-positive patients (41.1%; 95% CI, 34.4%–48.1%), whereas only 25.8% (95% CI, 20.0%–32.3%) preferred the CDC recommended dose of metronidazole 500 mg twice a day for 7 days in this subpopulation (Table 6). We found no association with any demographic characteristics and preferred treatment of HIV-positive patients according to CDC recommendations.
After treatment, only 9.6% (95% CI, 6.1%–14.3%) of respondents followed the CDC recommendations of retesting patients 3 months after treatment, with the remainder not testing at all (61.0%; 95% CI, 54.2%–67.5%) or testing sooner than 3 months. We found that the number of times a respondent tested for trichomoniasis in a typical month (OR, 1.02; 95% CI, 1.00–1.04) was associated with retesting at 3 months (Table 7). In the event of treatment failure, only 29% of providers followed the CDC recommended retreatment (metronidazole 500 mg twice a day for 7 days, Table 6). We found no association with any demographic characteristics and treating treatment failures according to CDC recommendations.
Less than half of respondents sought consultation from an infectious disease specialist for patients with trichomoniasis who were coinfected with HIV (38.8%; 95% CI, 32.3%–45.6%) or had hypersensitivity to a nitroimidazole (45.2%; 95% CI, 38.5%–52.1%). A plurality of respondents endorsed seeking consultation for a patient who fails to respond to treatment (53.4%; 95% CI, 46.6%–60.2%). Respondents reported rarely seeking consultation for patients who have only trichomoniasis (0%; 95% CI, 0.0%–1.7%), coinfection with PID (3.2%; 95% CI, 1.3%–6.4%), or are pregnant (2.8%; 95% CI, 1.0%–6.0%) (Table 6). For patients with trichomoniasis, a majority of respondents recommended concurrent treatment of all sex partners (91.9%; 95% CI, 87.4%–95.2%), and abstaining from sex (90.0%; 95% CI, 85.2%–93.7%) (Table 4).
This study assesses the knowledge, attitudes, and practices of obstetricians-gynecologists in the US regarding trichomoniasis. Provider knowledge reflects evidence-based understandings of trichomoniasis; the majority noted trichomoniasis is often asymptomatic2 and increases the risk of HIV acquisition3 and adverse pregnancy outcomes.5 The majority also test patients seeking care for vaginal discharge according to CDC guidelines14 and correctly identify NAAT as the test with the highest accuracy (although low sensitivity wet mounts, which can be performed at the point of care, were used by the highest proportion of providers). The majority also treat with standard doses for first line treatment in nonpregnant, non–HIV-positive women, and treat all sex partners concurrently.14 However, we note asymmetry in testing; nearly all providers recommend testing for other STIs if a patient has trichomoniasis, but only 69.5% test for trichomoniasis at least “most of the time” if a patient presents with another STI. More importantly, we note discrepancies between CDC recommendations and provider reported practices relating to screening of HIV-positive patients for trichomoniasis, treatment of trichomoniasis in HIV-positive patients with metronidazole 500 mg twice a day for 7 days, retesting cases diagnosed with trichomoniasis 3 months after treatment, and retreating patients with metronidazole 500 mg twice a day for 7 days after treatment failure.
Examining the demographics of providers may help explain these discrepancies between survey responses and CDC recommendations. We found that the frequency of testing for trichomoniasis patients was associated with following CDC guidelines to screen HIV-positive patients and retest patients 3 months after a course of treatment. The frequency of testing may be a measure of practitioner experience with trichomoniasis, which in turn may be associated with adherence to practice recommendations. Frequency of testing may be a more direct measure of experience specific to trichomoniasis than the number of years in practice, which in prior studies was associated with following practice recommendations in pelvic inflammatory disease15 but with incorrectly answering management questions on sexually transmitted diseases in accordance to CDC recommendations.16
This study has limitations. The response rate was 24.6%; responses captured in this study may not represent the knowledge of the ACOG population. Similarly, we noted a difference in primary practice type, and number of patients seen or tests for trichomoniasis in a typical month between CARN and non-CARN respondents (no non-CARN members were in obstetrics only practices, in contrast to 7.7% of CARN members). Despite these limitations, this study highlights important gaps in adherence to recommendations for screening and treatment of HIV-positive patients, and routine retesting and retreatment for trichomoniasis.
Appropriate screening and treatment in subpopulations that are HIV-positive, and repeat testing and providing treatment for trichomoniasis per national guidelines are important tools for controlling this highly prevalent, but “neglected” STI.17 The need for provider education—focusing especially on care for HIV-positive patients—is highlighted by our finding that the majority of respondents in our survey do not see trichomoniasis as a significant health issue despite its high prevalence and association with other STIs and pregnancy complications. The 2015 CDC STD treatment guidelines available online or as a smartphone app are one resource to assist providers in testing for and managing trichomonas infections.13
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