Point-of-Care Testing in Rural and Remote Australia: An Emerging Technology to Address Global Health Challenges, Crises and Security

Point-of-care (POC) testing enables rapid pathology results to be utilised in primary care settings for timely clinical decision-making and treatment during a patient consultation and can contribute to public health surveillance and responses. Large-scale POC testing networks (supporting 100 or more rural and remote health services) now operate for chronic, acute and infectious diseases across the length and breadth of Australia. Sound operator training, quality management and digital connectivity systems, in addition to strong clinical and cultural governance, underpin these networks, mitigate risks to patient safety, and facilitate scalability. Real-world examples from our Australian-based POC testing networks highlight how contemporary global health problems, such as diabetes, acute medical crises and the COVID-19 pandemic response can be addressed by the judicious application of POC testing in primary care settings. The recent role POC testing played in supporting First Nations communities of Australia during the pandemic serves as a template for and provides learned experiences that can be translated or adapted to other countries should or when future global security issues arise. The potential to use POC testing as an adjunctive diagnostic tool to support and enhance global health security needs to be balanced against the limitations of using this innovative technology

Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial

BACKGROUND: Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates. METHODS: In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16–34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis . We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044. FINDINGS: Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16–34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84–1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15–1·65; p=0·0006). INTERPRETATION: Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities.James Ward, Rebecca J Guy, Alice R Rumbold, Skye McGregor, Handan Wand, Hamish McManus, Amalie Dyda, Linda Garton, Belinda Hengel, Bronwyn J Silver, Debbie Taylor-Thomson, Janet Knox, Basil Donovan, Matthew Law, Lisa Maher, Christopher K Fairley, Steven Skov, Nathan Ryder, Elizabeth Moore, Jacqueline Mein, Carole Reeve, Donna Ah Chee, John Boffa and John M Kaldo

What works? Improving the uptake of STI testing and management among young people in remote Aboriginal and Torres Strait Islander communities in Australia

Aboriginal people living in remote communities experience a high burden of sexually transmissible infections (STIs). To interrupt the transmission of STIs and prevent complications, regular testing and timely treatment are required. The aim of this thesis is to provide new knowledge about the extent of regular testing, and barriers and facilitators to offering testing and timely treatment from the perspective of health staff working in these areas. Four studies were undertaken. The first, a longitudinal analysis, showed that among individuals attending 68 remote Aboriginal health services, 20.3% of those who had an initial chlamydia/gonorrhoea test were re-tested at 12 (+/-3) months, with rates higher in young people and females. Among both males and females, re-testing was more likely for those who attended a health service which saw predominantly Aboriginal clients. For females, re-testing was also more likely if they attended services which used electronic medical records, and for males, re-testing was more likely if they attended a service which employed Aboriginal health workers and more male staff. Studies 2 and 3, involved qualitative interviews with 36 staff working at 22 remote Aboriginal health services. Barriers for staff offering STI tests included; cultural norms requiring the separation of genders, competing clinical demands, concerns about client confidentiality and limited staff capacity. For timely treatment, barriers included; the large distances between the health centre and laboratories, delays in checking and actioning test results, under-utilisation of recall systems and difficulties in locating clients following receipt of a positive result. The fourth study systematically reviewed the international literature to assess the reach, uptake and outcomes of outreach as a strategy to increase testing coverage. The review revealed that despite the number of people tested being relatively small, the yield of infections was high. The proportion of the target population tested was higher in venues (community centres) but lower in street/public areas. In conclusion, the research in this thesis has identified client, cultural, health centre and systematic factors which impact on regular testing and timely treatment. Many of the barriers identified are modifiable, while others may require innovative strategies to overcome; such as outreach programs, point-of-care testing, and testing modalities outside the clinic

Chlamydia and gonorrhoea point-of-care testing in Australia: Where should it be used?

Background Diagnoses of chlamydia and gonorrhoea have increased steadily in Australia over the past decade. Testing and treatment is central to prevention and control but in some settings treatment may be delayed. Testing at the point of care has the potential to reduce these delays. We explored the potential utility of newly available accurate point-of-care tests in various clinical settings in Australia. Methods: In-depth qualitative interviews were conducted with a purposively selected group of 18 key informants with sexual health, primary care, remote Aboriginal health and laboratory expertise. Results: Participants reported that point-of-care testing would have greatest benefit in remote Aboriginal communities where prevalence of sexually transmissible infections is high and treatment delays are common. Some suggested that point-of-care testing could be useful in juvenile justice services where young Aboriginal people are over-represented and detention periods may be brief. Other suggested settings included outreach (where populations may be homeless, mobile or hard to access, such as sex workers in the unregulated sex industry and services that see gay, bisexual and other men who have sex with men). Point-of-care testing could also improve the consumer experience and facilitate increased testing for sexually transmissible infections among people with HIV infection between routine HIV-management visits. Some participants disagreed with the idea of introducing point-of-care testing to urban services with easy access to pathology facilities. Conclusions: Participants felt that point-of-care testing may enhance pathology service delivery in priority populations and in particular service settings. Further research is needed to assess test performance, cost, acceptability and impact

Point-of-care testing for chlamydia and gonorrhoea: implications for clinical practice

Objectives: Point-of-care (POC) testing for chlamydia (CT) and gonorrhoea (NG) offers a new approach to the diagnosis and management of these sexually transmitted infections (STIs) in remote Australian communities and other similar settings. Diagnosis of STIs in remote communities is typically symptom driven, and for those who are asymptomatic, treatment is generally delayed until specimens can be transported to the reference laboratory, results returned and the patient recalled. The objective of this study was to explore the clinical implications of using CT/NG POC tests in routine clinical care in remote settings. Methods: In-depth qualitative interviews were conducted with a purposively selected group of 18 key informants with a range of sexual health and laboratory expertise. Results: Participants highlighted the potential impact POC testing would have on different stages of the current STI management pathway in remote Aboriginal communities and how the pathway would change. They identified implications for offering a POC test, specimen collection, conducting the POC test, syndromic management of STIs, pelvic inflammatory disease diagnosis and management, interpretation and delivery of POC results, provision of treatment, contact tracing, management of client flow and wait time, and re-testing at 3 months after infection. Conclusions: The introduction of POC testing to improve STI service delivery requires careful consideration of both its advantages and limitations. The findings of this study will inform protocols for the implementation of CT/NG POC testing, and also STI testing and management guidelines

"I do feel like a scientist at times":A qualitative study of the acceptability of molecular point-of-care testing for chlamydia and gonorrhoea to primary care professionals in a remote high STI burden setting

BACKGROUND:Point-of-care tests for chlamydia (CT) and gonorrhoea (NG) could increase the uptake and timeliness of testing and treatment, contribute to improved disease control and reduce reproductive morbidity. The GeneXpert (Xpert CT/NG assay), suited to use at the point-of-care, is being used in the TTANGO randomised controlled trial (RCT) in 12 remote Australian health services with a high burden of sexually transmissible infections (STIs). This represents the first ever routine use of a molecular point-of-care diagnostic for STIs in primary care. The purpose of this study was to explore the acceptability of the GeneXpert to primary care staff in remote Australia. METHODS:In-depth qualitative interviews were conducted with 16 staff (registered or enrolled nurses and Aboriginal Health Workers/Practitioners) trained and experienced with GeneXpert testing. Interviews were digitally-recorded and transcribed verbatim prior to content analysis. RESULTS:Most participants displayed positive attitudes, indicating the test was both easy to use and useful in their clinical context. Participants indicated that point-of-care testing had improved management of STIs, resulting in more timely and targeted treatment, earlier commencement of partner notification, and reduced follow up efforts associated with client recall. Staff expressed confidence in point-of-care test results and treating patients on this basis, and reported greater job satisfaction. While point-of-care testing did not negatively impact on client flow, several found the manual documentation processes time consuming, suggesting that improved electronic connectivity and test result transfer between the GeneXpert and patient management systems could overcome this. Managing positive test results in a shorter time frame was challenging for some but most found it satisfying to complete episodes of care more quickly. CONCLUSIONS:In the context of a RCT, health professionals working in remote primary care in Australia found the GeneXpert highly acceptable. These findings have implications for use in other primary care settings around the world

Indicative STI management pathway (remote) with and without point-of-care testing.

<p>Indicative STI management pathway (remote) with and without point-of-care testing.</p