STIs in CHIEDZA

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Sexually transmitted infections (STI), when acquired in adolescence, can jeopardize sexual and reproductive health later in life, and for women, the health of their babies. In developing countries, symptomatic STIs are treated by syndromic management (presumptive treatment of symptomatic patients without the use of laboratory tests). Syndromic management was developed because diagnostic tests for STIs were unavailable in developing countries. However, research has shown that the accuracy of syndromic management for treating common STIs, like chlamydia and gonorrhoea, is low - especially for women. This is because most women with chlamydia and gonorrhoea do not have any symptoms. Yet these infections can have devastating outcomes such as pregnancy complications, infertility, and enhanced HIV transmission. Thus, effective STI control in adolescents and young people is a key priority in developing countries where both HIV and STIs are prevalent. Newer STI diagnostics integrated into HIV prevention and testing services may provide a solution.We plan to evaluate a STI screening intervention using newer STI diagnostic methods within a cluster randomised controlled trial among adolescents and young people (AYP) in Zimbabwe, called CHIEDZA. CHIEDZA is a community-based package of sexual reproductive health services incorporating HIV prevention, HIV testing, linkage to care for AYP aged 16 to 24 years. Our intervention will provide screening for the three most prevalent curable STIs (chlamydia, gonorrhoea and trichomoniasis) using point-of-care or near point-of-care tests.This study is timely: WHO is in the process of updating their STI case management guidelines and revisiting syndromic case management. Robust evidence for integrating newer testing technologies for AYP is needed to inform these guidelines.Our questions are 1. What is the uptake, prevalence and yield of community-based STI screening among AYP?All CHIEDZA attendees will be offered chlamydia and gonorrhoea screening and young women will also be offered testing for trichomoniasis. The outcome will be uptake, prevalence (proportion positive for an STI of those screened) and yield (proportion positive for an STI of those eligible for screening). 2. What is the impact of community-based STI screening and comprehensive management on population level STI prevalence among AYP? A population-based cross-sectional survey is planned for the CHIEDZA trial following the intervention period. STI testing will be added for a random sub-sample of participants in the cross-sectional survey. The primary outcome will be a comparison of the percentage of individuals with a positive test for chlamydia, gonorrhoea or trichomoniasis between intervention and control clusters using the two-stage approach for analysis of CRTs.3. Can a risk assessment tool predict STI positivity among asymptomatic AYP? During the STI screening intervention, data on risks and genital symptoms will be collected. A self-assessment tool will be developed using for k-fold cross validation methods. The outcome will be sensitivity, specificity, positive predictive value and negative predictive value of the assessment tool for STI positivity.4. Is community-based STI screening and comprehensive management cost-effective? We will measure how cost-effective our intervention is compared to syndromic management.5. Is community-based STI screening and comprehensive management acceptable and what factors need to be addressed to ensure that the intervention can be scaled-up and sustained at a national level if it is effective? We will conduct a process evaluation to understand how our intervention works, whether it is acceptable to clients and providers and specifically to understand the factors that would need to be considered to ensure the intervention could be delivered widely within the country if it was proven effective.