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ObjectivesTo assess risk and protective factors associated with bacterial vaginosis (BV) chronicity ascertained by Nugent score criteria.MethodsA longitudinal cohort study included 255 sexually experienced, postmenarcheal women who provided weekly self-collected vaginal swabs for up to 2 years. Vaginal swabs were scored using Nugent criteria and classified as normal (≤3), intermediate (4–6) and Nugent-BV (≥7). Detailed behavioural/health information were assessed every 6 months. A per-woman longitudinal summary measure of BV chronicity was defined as the percentage of each woman’s weekly vaginal assessments scored as Nugent-BV over a 6-month interval. Risk and protective factors associated with BV chronicity were assessed using multiple linear regression with generalised estimating equations.ResultsAverage BV chronicity was 39% across all follow-up periods. After adjustment, factors associated with BV chronicity included baseline Nugent-BV (β=35.3, 95% CI 28.6 to 42.0) compared with normal baseline Nugent scores and use of unprotected water for bathing (ie, rainwater, pond, lake/stream) (β=12.0, 95% CI 3.4 to 20.5) compared with protected water sources (ie, well, tap, borehole). Women had fewer BV occurrences if they were currently pregnant (β=−6.6, 95% CI −12.1 to 1.1), reported consistent condom use (β=−7.7, 95% CI −14.2 to 1.3) or their partner was circumcised (β=−5.8, 95% CI −11.3 to 0.3).ConclusionsFactors associated with higher and lower values of BV chronicity were multifactorial. Notably, higher values of BV chronicity were associated with potentially contaminated bathing water. Future studies should examine the role of waterborne microbial agents in the pathogenesis of BV.

ObjectivesPathogen load has been linked to disease severity in patients infected with HIV, resulting in international standards to adequately and reproducibly quantify load.Chlamydia trachomatis(CT) load has been inconsistently linked to disease severity since extensive differences exist in quantification methods (14 methods in 28 articles). Differences include normalisation for human cell load due to CT’s intracellular nature, despite the inability to distinguish inflammatory cells from epithelial cells with molecular techniques. We compared the human cell load in CT-positive men and women at the genital and anal site to a CT-negative control group to estimate the impact of inflammatory cells in these samples.Methods188 women (tested at genital and anal site) and 519 men (207 tested at the anal site and 312 tested at the urogenital site) were included from our STI-clinic in the Netherlands. Specimens were self-collected vaginal swabs, anal swabs and urine samples. Quantitative-PCR targeting the HLA-gene quantified human cell load. Mann-Whitney-U-test was used for statistical analyses.ResultsThe genital cell load had a similar range and median (6.5 log10) between CT-negative and CT-positive women . The urogenital cell load was significantly higher than the anal cell load (median 3.6 log10). The anal cell load was significantly higher in men with- than without anal CT infection (median 4.5 versus 3.9 respectively). The anal cell load is significantly higher in CT-positive men than in women. Both Neisseria gonorrhoeae-co-infections and reported anal intercourse significantly increased the human cell load in anal samples.ConclusionStandardisation in CT load studies is necessary as current studies show 14 different quantification methods in 28 studies . In this study we demonstrate the inappropriateness of normalising the CT load for the human cell load using molecular techniques, as the presence of inflammatory cells cannot be excluded.

Background WHO estimates that 131 million new cases of urogenital Chlamydia trachomatis (CT) infections occur globally every year. Most infections are asymptomatic. Untreated infection in women can lead to severe complications. Screening and treatment of at-risk populations is a priority for prevention and control. Objectives To summarise systematic reviews of the performance characteristics of commercially available point-of-care tests (POCT) for screening and diagnosis of urogenital CT infection. Methods Two separate systematic reviews covering the periods 2004–2013 and 2010–2015 were conducted on rapid CT POCTs. Studies were included if tests were evaluated against a valid reference standard. Results In the first review, 635 articles were identified, of which 11 were included. Nine studies evaluated the performance of eight antigen detection rapid POCTs on 10 280 patients and two studies evaluated a near-patient nucleic acid amplification test (NAAT) on 3518 patients. Pooled sensitivity of antigen detection tests was 53%, 37% and 63% for cervical swabs, vaginal swabs and male urine, and specificity was 99%, 97% and 98%, respectively. The pooled sensitivity and specificity of the near-patient NAAT for all specimen types were >98% and 99.4%, respectively. The second review identified two additional studies on four antigen detection POCTs with sensitivities and specificities of 22.7%–37.7% and 99.4%–100%, respectively. A new two-step 15 min rapid POCT using fluorescent nanoparticles showed performance comparable to that of near-patient NAATs. Conclusions The systematic reviews showed that antigen detection POCTs for CT, although easy to use, lacked sufficient sensitivity to be recommended as a screening test. A near-patient NAAT shows acceptable performance as a screening or diagnostic test but requires electricity, takes 90 min and is costly. More affordable POCTs are in development.

Background In 2012, there was an estimated 78 million new cases of gonorrhoea globally. Untreated infection may lead to reproductive and neonatal morbidity and facilitate HIV transmission. Diagnosis and treatment are a priority for control and prevention, yet use of point-of-care tests (POCTs) for Neisseria gonorrhoeae (NG) is limited. Objectives To review the performance and operational characteristics of NG POCTs for diagnosis of urogenital gonorrhoea. Methods We compiled and synthesised findings from two separate systematic reviews which included evaluations published until August 2015. Results Six tests were included: five were immunochromatographic tests (ICTs) or optical immunoassay (OIAs) based on antigen detection; with 5–7 steps and results in 25–40 min, and one (GeneXpert CT/NG) was a ‘near-patient test’ based on nucleic acid amplification technique (NAAT); with three steps, electricity required, and results in 90 min. When compared with laboratory-based NAATs as the reference tests, sensitivities of ICT and OIA-based POCTs ranged from 12.5% to 70% when cervical/vaginal swabs were tested. Specificities ranged from 89% to 99.8%. The near-patient NAAT had sensitivities of >95% and specificities of >99.8% consistently across all specimen types (urine, cervical and vaginal swabs). Conclusions Based on a limited number of evaluations, antigen detection POCTs for NG lacked sufficient sensitivity to be used for screening. A near-patient NAAT has acceptable performance, only involved a few steps, but needs electricity, a temperature-controlled environment and has a 90 min run time. To achieve wider scale up of NG POCTs, we need strong evidence of cost-effectiveness, which should inform guidelines and ultimately increase test development, demand and reduce costs.

Objective To determine if human papillomavirus (HPV) DNA can be detected on the transvaginal sonography (TVS) probe in the emergency department (ED) and whether the current barrier method plus disinfection can prevent HPV contamination of the TVS probe. Methods This was a two-part cross-sectional study. In the first part, surveillance samples were taken from the TVS probe for HPV DNA detection daily for 2 months. In the second part, patients presenting with early pregnancy complications were identified in the ED and high vaginal swabs were taken for HPV DNA testing. Several probe swabs were taken to identify if contamination was possible in cases where the procedure was done on an HPV carrier. Results A total of 120 surveillance samples were obtained, nine of which (7.5%) tested positive for HPV DNA. In the second part, 76 women were recruited, of whom 14 (18.4%) were HPV carriers. After the procedure and disinfection of the probe, three out of the 14 probe samples (21%) were HPV DNA positive. Conclusions HPV is commonly encountered in the ED and contamination of the TVS probe with HPV is possible. Although it is difficult to prove the viability and infectivity of the virus, vigilant infection control measures should be maintained.

Objectives To compare self-collected vaginal swab (SCVS) types and first-catch urine (FCU) to diagnose Trichomonas vaginalis using analyte-specific reagents designed to be used in a transcription-mediated amplification assay. Methods A total of 241 women (group A) collected a FCU and a SCVS using a dacron swab (APTIMA collection kit). A second group of 289 women (group B) collected two SCVS using one dacron swab and one nylon-flocked swab. Results Of 75 young women (street youth) determined to be infected with T vaginalis only seven reported symptoms of vaginal discharge or irritation. Using a cutoff of 50 000 relative light units, the sensitivity and specificity was 97.2% and 97.6%, respectively for dacron SCVS compared with 41.7% and 100% for FCU in group A; 92.3% and 98.8% for dacron SCVS and 92.3% and 99.2% for flocked-nylon SCVS in group B. The assay tested 96 samples in 6 h. Conclusions Dacron and nylon-flocked SCVS performed equally well and significantly better than FCU using analyte-specific reagents in the APTIMA transcription-mediated amplification assay. Either swab type could be used for self-collection.

Background/introduction Vaginal discharge and vulvitis are common presenting symptoms in both sexual health services and general practice. Due to various constrains particularly in general practice, examination of a patient may not be possible. Syndromic management is often practiced but can be unreliable. Few studies to date have specifically looked at the validity of self-collected vulvovaginal swab for the diagnosis of bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC) Aim(s)/objectives To describe agreement between self-collected vulvovaginal swabs and clinician taken high vaginal swabs for the detection of BV and VVC. Design Case controlled study with the patient acting as her own control. Setting An urban sexual health centre. Participants: Women aged 16–65 years attending with symptomatic vaginal discharge, vulval irritation or an offensive genital smell. Interventions: Participants took a vulvovaginal swab prior to speculum insertion and vaginal examination during which a clinician took a high vaginal swab. Main outcome measure: Diagnosis of BV or VVC infection with samples analysed in a microbiology department using both microscopy and culture. Results 104 women were enrolled in the study. Of these 45 were diagnosed with VVC. 26 were diagnosed with BV. Using the reference standard of laboratory testing, the sensitivities of self-collected vulvovaginal swabs for BV and VVC were 88.5% and 95.5% respectively. The Cohen Kappa score showed strong agreement for the detection of both BV and VVC (k = 0.842 and k = 0.878 respectively). Discussion/conclusion Self-collected vulvovaginal swabs appear to be a valid alternative to clinician taken high vaginal swabs for detecting BV and VVC infections.

Introduction New molecular-based point-of-care (POC) tests for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are being used for the first time by trained Aboriginal health workers/practitioners, registered/enrolled nurses and medical officers in regional/remote health services in Australia as part of TTANGO (Test, Treat ANd GO). We assessed the operational performance of the GeneXpert®CT/NG assay (Cepheid) POC test using conventional laboratory tests as the reference standard. Methods TTANGO, a randomised cross-over control trial of CT/NG POC testing, commenced June 2013. To date, 12 services have implemented GeneXpert testing on-site as routine practice, with specimens still sent to jurisdictional laboratories for conventional nucleic acid amplification testing (NAAT) as usual. We assessed the concordance of GeneXpert performed by health service staff with conventional laboratory NAAT. We also present selected details of discordant specimens. Results Among 1995 GeneXpert tests performed, CT and NG were detected in 182 and 127, respectively, by the jurisdictional laboratory. CT concordance was 99.4% (95% CI: 99.0 – 99.8) and NG was 99.9% (99.6–100.0). The fourteen discordant results (eight urines, six lower vaginal swabs) were identified in seven services and five laboratories (two use Cobas 4800, three use Aptima). Discordant results were predominantly CT (n = 12) and most (n = 10) were positive POC/negative laboratory results. The median POC test crossing point among CT discordants was 37.2 (IQR: 31.6–37.7) with five of nine (55.6%) having crossing points >35, compared to 29.2 (IQR: 26.3–32.6) among CT concordants with 10 of 179 (5.5%) having crossing points >35. The two NG discordant results were both positive POC/negative laboratory results. Conclusion The performance of GeneXpert in the hands of trained health service staff is excellent and consistent with previous laboratory and field evaluations. Higher crossing points of discordant results most likely indicates low organism loads close to test detection threshold and seem unrelated to service, laboratory, specimen type or reference assay. Overall, results show the GeneXpert method is suitable for routine detection of CT and NG. Disclosure of interest statement No conflicts of interest declared. No financial support was received by Cepheid. Cepheid has provided GeneXpert devices on loan for the duration of TTANGO and test cartridges at a reduced rate.

Introduction The pigtailed macaque model for trichomonal infection was used to compare T. vaginalis (TV) detection technologies, to describe infection status in younger versus older populations, and to test whether TV reinfection after antibiotic clearance is possible in this model. Methods Thirty-six macaques received a single vaginal TV inoculation (ATCC 50148; ~6E5), followed by five weekly visits to document infection. Eighteen animals were 4–7 years old; eighteen were over 13 years old. Infection status was documented by culture (InPouchTV) and by NAAT (AptimaTV). Colposcopy was performed to assess tissue reaction to infection. Animals underwent antibiotic treatment (metronidazole) and test-of-cure. Five macaques from the younger cohort were later re-inoculated with the same TV strain and followed for three weeks to document reinfection. Results All but one (older) animal were successfully infected after the initial vaginal challenge. Among 295 matched samples (culture/NAAT), 22 did not share confirmatory results. In this experimental setting, with weekly vaginal swabs providing a timeline of trichomonal presence in each animal, we can infer infectious status for some discrepant samples. It is likely that 10–12 instances can be attributed to false culture readings, and 3–5 to false NAAT results. Self-limited infections were noted more frequently among younger macaques. Friable tissue was noted more frequently among older animals. Four of the five animals that were re-challenged with TV developed infection. Conclusions The NAAT gave fewer false results, when we had the luxury of a timeline of serial samples to refer to for determining test accuracy. Similar infection rates were observed in both age cohorts. Older animals had a greater incidence of cervicovaginal irritation evidenced primarily by friability in this study, and younger animals tended to self-clear T. vaginalis infection faster than older animals. Finally, TV re-infection is possible in the macaque model. Disclosure of interest statement This research was supported by NIH Contract Number HHSN266200700013C and by the Office of Research Infrastructure Programs (ORIP) of the National Institutes of Health through Grant Number P51 OD010425 Washington National Primate Research Centre. No pharmaceutical grants were received in the development of this study.

Introduction Repeat infections of chlamydia are very common and may represent a new infection, re-infection from an untreated partner or treatment failure. The aim of this cohort study is to estimate the proportion of women infected with chlamydia who experience failure after treatment with 1 gram azithromycin. Methods Women diagnosed with chlamydia were followed for 8 weeks post treatment with 1 gram azithromycin and provided weekly genital specimens for further assay. The primary outcome was the proportion of women classified as having treatment failure at least 4 weeks after recruitment. Comprehensive sexual behaviour data collection and the detection of Y chromosome DNA in vaginal swabs and genome sequencing were used to differentiate between chlamydia re-infection and treatment failure. Chlamydia culture and MIC was also undertaken. Results There were 305 women recruited with a response rate of 66%. A total of 36 women were diagnosed with repeat chlamydia infection during follow up (11.8%; 95% CI: 8.4%, 16.0%). The median time till repeat infection was 7 weeks, with 25% of repeat infections diagnosed within 5 weeks. The risk of repeat infection increased with increasing organism load of initial infection (OR = 1.6; 95% CI: 1.2, 2.8 for each additional log increase in load). Of the 36 women with repeat infection, 16 (44.4%; 95% CI: 27.9%, 61.9%) were classified as treatment failure with an overall risk of treatment failure of 5.2% (95% CI: 3.0%, 8.4%). There was no detectable shift in MIC between initial and repeat infections with MIC within reported antimicrobial susceptibility ranges. Conclusion Using a combination of advanced laboratory techniques and comprehensive sexual behaviour data, we estimate that about 1 in 20 women with chlamydia infection treated with 1 gram of azithromycin will fail treatment. Further laboratory investigation will determine whether there are any genomic characteristics of the infections associated with treatment failure in our cohort. Disclosure of interest statement This study was funded by the NHMRC.

Introduction Alterations in vaginal microbiota associated with intrauterine contraception may impact host susceptibility to sexually transmitted infection. We evaluated the effect of the levonorgestrel intrauterine system (LNG-IUS) on cervical persistence of Chlamydia trachomatis (CT) in a baboon model and whether CT persistence was correlated with vaginal microbial community structure. Methods 20 wild caught female olive baboons ( Papio abubis ) were randomly assigned to receive either LNG-IUS and CT inoculation (n = 8), LNG-IUS and sham inoculum (n = 2), CT inoculation alone (n = 8), or sham inoculation (n = 2). Animals were acclimated to the LNG-IUS for 24 weeks after which animals were cervically inoculated once weekly for 5 weeks. Vaginal swabs were collected weekly for microbiome analysis by 16S rRNA-encoding gene sequence analysis. Presence of CT in the cervical epithelium was confirmed with weekly nucleic acid amplification testing (NAAT) and culture. Results Use of the LNG-IUS was significantly associated with positive CT culture (p = 0.04) but not NAAT (p = 0.07). Median time to cervical clearance of CT as detected by NAAT was 12.5 days (range 5–16) for LNG-IUS animals in comparison to 7 days (range 3–10) for non-implanted animals (p = 0.14). Similarly, median time to cervical clearance of CT by culture was 12 days (range 5–15) for LNG-IUS animals and 5 days (range 1–10) for non-implanted animals (p = 0.05). We did not detect significant within group differences between vaginal microbial community structure at baseline and following LNG-IUS insertion, CT inoculation, or LNG-IUS and CT in combination. Conclusions Use of the LNG-IUS was associated with a trend towards cervical persistence of CT in a baboon model. However, this persistence is not explained by alterations in vaginal microbial communities. Disclosure of interest statement The authors have no disclosures to report.

Introduction Prevalence and incidence of HIV infection and other sexually transmitted infections (STIs) are particularly high among adolescent girls in sub-Saharan Africa. The role played by the vaginal microbiota in susceptibility to HIV and other STIs in adolescent girls is unclear. The aim of this study was to characterise the vaginal microbiota of adolescent girls in Tanzania around the time of their sexual debut. Methods Girls aged 17–18 years old attending secondary schools in Mwanza City were invited to join a cross-sectional study. After informed consent/assent, girls were interviewed and vaginal swabs were obtained and tested for the following species by in-house quantitative PCR: Lactobacillus crispatus, L. iners , L. gasseri, L. jensenii, L. vaginalis, Atopobium vaginae, and Gardnerella vaginalis . Differences in the prevalence of bacterial species were analysed using logistic regression. Results Of the 403 girls enrolled, 385 provided samples for this analysis. Of these, 163 reported having had sexual intercourse. Prevalences of bacterial species were as follows (overall; sexually active/sexually naive): L. crispatus (69%; 60%/75%), L. iners (83%; 85%/80%), L. gasseri (22%; 21%/23%), L. jensenii (49%; 40%/55%), L. vaginalis (66%; 55%/74%), A. vaginae (44%; 56%/34%), and G. vaginalis (62%; 75%/52%). Prevalences of A. vaginae and G. vaginalis were higher among girls who reported sexual intercourse (OR: 2.5; 95% CI: 1.7–3.8 and OR: 2.8; 95% CI: 1.8–4.4, respectively), while prevalences of L. crispatus, L. jensenii, and L. vaginalis were lower in sexually active girls (OR: 0.5; 95% CI: 0.3–0.8, OR: 0.5; 95% CI: 0.4–0.8, and OR: 0.4; 95% CI: 0.3–0.6, respectively). Conclusion Among girls attending secondary school in Tanzania, sexual debut was associated with quantifiable changes in vaginal microbiota. BV-associated bacteria were present in many girls before reported sexual debut. Additionally, the prevalence of L. crispatus was higher than expected; a recent study showed the prevalence among African women to be relatively low (17–38%). This challenges the view that women in sub-Saharan Africa have less L. crispatus colonisation. Disclosure of interest statement The authors do not have a conflict of interest. No pharmaceutical grants were received in the development of this study.

Background Rescreening women for Trichomonas vaginalis (TV) post treatment is important as repeat infections are common, ranging from 5%–31%. Nucleic acid amplification testing (NAAT) too soon after treatment may result in false positive results due to detection of remnant TV nucleic acids. The goal of this study was to determine the rate of false positive NAAT results at weeks 1–4 post treatment completion using culture as the gold standard. Methods Women attending an STI clinic in New Orleans who were InPouch culture positive and treated with metronidazole (MTZ) were included. Participants were scheduled for 4 weekly follow up visits beginning one week post-treatment completion. They provided self-obtained vaginal swabs (SOVS) and information regarding sexual exposure at each visit. SOVS were tested using InPouch culture and the Gen-Probe AptimaTV (GPATV) assay which targets ribosomal RNA. Women who were culture positive at follow-up were considered re-infected/treatment failure and were not followed further. Results 39 women were InPouch+ at baseline and were followed. Of these, 3 (7.7%) were InPouch TV+ at follow-up (1 at 1 week and 2 at 2 weeks) and reported no sexual exposure. Thus, these women were considered to be treatment failures and were no longer followed. Of the remaining cases, 5/29 (17.2%) were GPATV+ at the 1 week follow up visit, and 1/34 (2.9%) was GPATV+ at 2 weeks. The six positive women denied vaginal sexual re-exposure. None of the women were InPouch TV culture positive at any of the follow up visits and no woman was GPATV+ at 3 and 4 weeks post treatment. Conclusions These data demonstrate that TV ribosomal RNA is cleared from the vagina by 3 weeks post completion of successful MTZ treatment and that the GPATV assay can be relied on as a test-of-cure at this point and beyond. Disclosure Drs Martin and Taylor have served as consultants for Hologic Inc.

Introduction The Aptima TV NAAT for the detection of Trichomonas vaginalis (TV) is ~100% sensitive compared to wet mount microscopy (50%) or culture (75%). Asymptomatic women attending genitourinary medicine (GUM) clinics and patients in primary care are often not tested for TV, as the prevalence and sensitivity of current tests is assumed to be too low for testing to be cost effective. Our aim was to determine how many additional cases were identified with the new test and whether self-taken and clinician-taken vaginal swabs are of equivalent sensitivity in symptomatic GUM patients. Methods Patients were tested using the Aptima TV NAAT alongside existing testing methods. Results The positivity of TV determined by TV NAAT was 4.8% (26/543) and 1.8% (28/1593) in women with and without symptoms attending GUM and 2.7% (95/3512) and 1.1% (41/3593) respectively in primary care. TV NAAT significantly outperformed our existing testing methods. In a subset of 491 GUM patients in whom all tests were performed, 14/23 (61%) TV NAAT positive patients were identified on wet prep or culture (p = 0.004). In a subset of 2930 primary care patients in whom all tests were performed, 19/74 (26%) TV NAAT positive patients were identified on wet prep or culture (p Self- taken vaginal swabs were equivalent in sensitivity to clinician taken swabs; of the 26 patients who tested positive on either NAAT test, 25 tested positive on self-taken swab and 21 tested positive on clinician taken swab (p = 0.51). Conclusion Testing women attending GUM clinics and in primary care with the Aptima TV NAAT test will identify additional cases and should replace conventional microbiological testing methods if found to be cost-effective. Disclosure of interest statement Hologic provided the tests for the Aptima TV NAAT research study and have sponsored the authors to present this data at ISSTDR.

Background/introduction There is a low prevalence of Trichomonas Vaginalis (TV) in the area where the clinics are based. Screening has been performed by wet preparations. BASHH guidelines have suggested the test of choice is nucleic acid amplification test (NAAT) where resources allow- Would a TV NAAT detect more cases? Aim(s)/objectives To compare detection rates of TV using a wet preparation, direct fluorescence, culture and NAAT tests in symptomatic female patients. Methods The evaluation was performed in 2 stages. In the first stage, 218 symptomatic female patients had a high vaginal swabs (HVS) taken for a wet preparation and for fluorescence and culture for TV In the second stage 126 symptomatic female patients had HVS taken for wet preparation, fluorescence, culture and a further sample for TV NAAT by two methods of real time PCR. Results 218 patients were tested in the first stage – 218 results were negative via wet preparation as well as via fluorescence and culture. In the second stage 124 results were negative via the wet preparation compared to 125 tests via culture/ fluorescence. There were 3 tests positive via NAAT (2 were positive via wet prep/culture/fluorescence. 1 was negative via wet prep but positive via culture/fluorescence). 2 tests were inhibitory via NAAT (negative via wet prep/culture/fluorescence). Discussion/conclusion In this sample of symptomatic patients, the TV NAAT detected less than 1% (1/124) additional positive results. We conclude that in this low prevalence area for TV, a wet preparation from an HVS is satisfactory for screening symptomatic female patients.

Background The Aptima TV NAAT test has been approved for use for the detection of Trichomonas vaginalis ( TV ) and is more sensitive (˜100%) than wet mount microscopy (50%) or culture (75%). Asymptomatic women attending GUM clinics are often not tested for TV as the prevalence is assumed to be too low for testing to be cost effective. Aims To determine TV positivity rate among GUM attendees with and without symptoms How many additional cases are identified with the new test Whether self-taken vaginal swabs are of equivalent sensitivity in symptomatic GUM patients. Methods Patients were tested using the Aptima TV NAAT alongside existing testing methods. Test performance was compared using the McNemar test. Results The positivity of TV determined by TV NAAT was 4.2% (22/519) in symptomatic and 1.8% (28/1599) in asymptomatic women. 9/20 NAAT positive patients, where all test were performed, would not have been identified on wet prep or culture. Overall TV NAAT outperformed currently used methods (p = 0.004), clinic wet prep vs NAAT (p = 0.038), culture vs NAAT (p = 0.002). Self-taken vaginal swabs were equivalent in sensitivity to clinician taken swabs; of patients who tested positive on either NAAT test, 19 tested positive on self-taken swab and 17 tested positive on clinician taken swab (p = 0.625). Conclusions Testing all women attending GUM clinics with the APTIMA TV NAAT test will identify additional cases and is therefore likely to be cost-effective, and should be considered to replace conventional microbiological testing methods.

Background Over 350 million (M) prevalent cases of curable STIs are estimated worldwide: 100 M chlamydia (CT), 36M gonorrhoea (NG), 187 M trichomonas, and 36 M cases of syphilis. 34 M HIV infections are estimated worldwide. Human papillomavirus infections (HPV) and herpes viruses (HSV) are highly prevalent, yet are not often diagnosed. Technology has led to sensitive nucleic acid amplification tests (NAATs), allowing use of non-invasive specimens, like vaginal swabs and urine. NAATs are widely available, and novel approaches include point-of-care (POC) tests, internet availability, and self-testing. New serological tests have advanced diagnoses of HIV, HPV, and HSV. Yet, challenges to diagnosing STIs continue. Methods To discern where we are heading in the field of HIV/STI diagnostics research, new assays and new approaches to enhance care were reviewed. Results There are commercial NAATs for CT/NG by 4–5 companies. Some are available on expensive robotic platforms, limiting their use in resource-constrained settings. Additionally, a new CT/NG NAAT that can return results in 90 minutes is available. Other rapid NAAT and hybridization POC assays are in the pipeline. There are two NAATs and a POC test for trichomonas. POC syphilis serology tests have proliferated, which is important to syphilis elimination. Several platforms offer NAAT tests for HPV and there is a NAAT for HSV ulcers. Rapid HIV POC and 4 th generation tests have advanced earlier detection of HIV. A home oral-fluid HIV test can be purchased in the US. Patients perform their own HIV tests in Emergency Departments with excellent accuracy. Internet availability of select STI tests for home collection/outreach programmes offer novel approaches to increasing options offered to individuals at risk. Conclusions Learning how to wisely and effectively use these tools can improve the detection of STIs and provide cost-effective ways to increase the number of patients being treated.

Background This study evaluated the clinical performance of the APTIMA® Trichomonas vaginalis (ATV, Gen-Probe Incorporated) Assay, a nucleic acid amplification test for the diagnosis of Trichomonas vaginalis (TV) infection, in asymptomatic and symptomatic women. Methods This prospective, multicenter clinical trial enrolled 1025 women attending US OB-GYN, adolescent, family planning, or sexually transmitted disease clinics. Four specimen types were collected from each subject: physician-collected vaginal swab, endocervical swab, ThinPrep specimen, and first-catch urine. Of three vaginal swabs collected from each subject, one was used for wet mount microscopic examination, one for culture, and one for molecular testing for TV. The order of collection for each vaginal swab sample was rotated to minimise sampling bias. Each specimen was tested by ATV assay using the automated TIGRIS DTS system. ATV assay performance in each sample type was determined by comparing ATV assay test result to the patient infected status (positive in saline wet mount and/or culture) for each sample. Results Of 933 subjects included in the analysis, 59.9% were symptomatic. Compared to patient infected status, ATV assay clinical sensitivities and specificities were 100% and 99.0%, respectively, from vaginal swabs; 100% and 99.4%, respectively, from endocervical swab; 100% and 99.6%, respectively, from ThinPrep specimens; and 95.2% and 98.9%, respectively, from patient-collected urine samples. ATV assay performance was similar in asymptomatic and symptomatic patients, by age group (14–17 years and 18 years or older), and was consistent between testing sites. The ATV assay also demonstrated superior performance compared to wet mount microscopic examination and TV culture, regardless of the specimen type utilised. Conclusions This study provides clinical validation of the ATV assay for the intended uses of detecting TV rRNA in asymptomatic women, and/or to aid in the diagnosis of trichomoniasis in symptomatic women, in a US population. The use of highly accurate, fully-automated molecular tests such as the ATV assay for testing easily obtained vaginal swab and urine samples should facilitate large-scale screening for TV in the US.

Background The website http://www.iwantthekit.org/ (IWTK) began offering self-administered rectal swab kits in addition to vaginal swab kits in January 2009 to test for Chlamydia trachomatis , Neisseria gonorrhoeae , and Trichomonas vaginalis . Methods Swab samples were collected at home by participants and sent by US mail and tested by NAAT (Gen-Probe) assays. Participants submitted separate questionnaires for the vaginal and rectal kits. Data were analysed by STATA, version 11. Results In 1084 questionnaires from women submitting vaginal swabs to the IWTK program since 2009, 194 (17.9%) reported anal intercourse (AI) in the last 90 days. Of these women, only 113 (58.2%) also ordered and returned rectal kits for testing. An additional 95 kits were ordered and returned by women who did not report recent AI (82), did not return a vaginal swab (5), or did not answer the AI question on the vaginal questionnaire (8). From a total of 406 rectal kits ordered by women overall, 208 (51.2%) were returned; three had no consent form; thus, 205 were tested. Of those tested, 26 (12.7%) were positive for chlamydia, 5 (2.4%) were positive for gonorrhoea, and 13 (6.3%) were positive for trichomoniasis. Two of these samples were positive for both Chlamydia and gonorrhoea, two for both chlamydia and trichomonas, and one for all three STIs. The total number of women testing positive for any rectal STI was 38 (18.5%), and 35 of these women also received and returned vaginal swabs, 34 of which were tested. Of those tested, 24 (70.5%) were positive for at least one of the three STIs vaginally, indicating that women who tested positive for rectal STIs were at very high risk for vaginal STIs. Of the 38 women with rectal STIs, the median age was 22 yr. and the median age of first rectal sex was 20 yr. Questionnaires demonstrated 93.6% were single, 62.5% were Black, and 21.9% were White. Of the women with rectal STIs, 67.7% reported no symptoms, 12.0% reported no rectal partners in previous yr, 56.0% reported one partner, and 32% reported 2–4 partners. Only 16.0% reported having a new rectal partner in the last 3 months. Half (50.0%) reported never using condoms, 15.4% reported they always used condoms, 15.4% reported using condoms most of the time, and 19.2% reported using condoms some of the time. Conclusions Public health officials should be aware that AI and rectal STIs are not uncommon among sexually active women. Future STI screening programs should consider rectal infections.

Background The Roche cobas 4800 (cobas) is a new diagnostic assay that utilises an automated workstation to isolate nucleic acids from clinical specimens and a real time instrument for the detection of C trachomatis (CT) and N gonorrhoeae (NG). The objective of this study was to compare the performance characteristics of the cobas to the BD Viper (Viper) and GenProbe Aptima Combo 2 (AC2) assays for the detection of CT and NG using a patient infected standard (PIS). Methods Specimens were obtained from women attending STD, family planning, or OB/GYN clinics from 12 geographically distinct locations. Endocervical swabs (ES) and samples in ThinPrep liquid based cytology medium (LBC) were obtained from each participant as were urine samples (data not shown) and vaginal swabs (data not shown). LBC were sampled prior to cytology (prequot) for cobas and AC2 and after cytology (postquot) for cobas only. A patient was considered infected if at least 2 of the assays with different molecular targets gave positive results from the ES or urine samples. Results Overall CT sensitivity ranged from 89.7 to 92.8% and specificity ranged from 99.6 to 99.8% for all sample types. Overall GC sensitivity ranged from 95.6 to 97.1% and specificity from 99.9 to 100% see Abstract P3-S1.34 table 1. Conclusions The cobas assay has excellent sensitivity and specificity when compared to PIS. Equivalent performance was observed for the ES and LBC samples, providing clinicians with flexibility to tailor endocervical sample acquisition to their particular setting. There was no statistical difference between the pre- and post-quot LBC samples allowing specimen handling to be suited to the needs of the microbiology and cytology laboratories. The assay is easy to perform, automated, and can be completed in

Background Family planning clinics provide contraceptive and preventive services for millions of low-income individuals. Screening and treatment for Chlamydia trachomatis infection in these clinics is a major part of the chlamydia control program in the USA. For women diagnosed with chlamydia, rescreening 3 months after treatment is recommended according to national guidelines. However, rescreening rates are low. The time and effort needed for patients to return to the clinic and the lack of access to follow-up care may contribute to the poor adherence to the rescreening recommendation. Methods We conducted a randomised controlled trial in family planning clinics in three cities. After informed consent, women/girls >16 years treated for laboratory-confirmed chlamydial infection were randomly assigned to the Home Group (mailed a vaginal swab kit for self collection at home) or the Clinic Group (made a clinic appointment) for rescreening at 3 months following treatment. Reminder calls were made about 2 weeks before scheduled rescreening. The endpoint was rescreening within a 7 week window, 1 week before to 6 weeks after, the scheduled rescreening date. Results 404 women were enrolled and their group assignments were randomised by opening centrally stuffed envelops. Women assigned to the Home Group had higher rescreening rate than those in the Clinic Group: Overall, 40.8% of 196 in the Home Group and 20.7% of 208 in the Clinic Group were rescreened (p Conclusions Use of home-based, self-obtained vaginal swabs resulted in a significant increase in rescreening rates compared to rescreening in the clinic. Our findings indicate a role for home-based specimen collection as an alternative to clinic-based rescreening for chlamydia in women.

Background US guidelines recommend chlamydia screening for all sexually active young women, HIV-infected persons, and men who have sex with men (MSM). Several types of chlamydia tests are available, including nucleic amplification tests (NAATs), DNA probe, and culture. Different assays have different sensitivity and specificity, and sensitivity and specificity also varies by specimen type. Because reported chlamydia trends could be impacted by shifts in the proportion of tests and specimen types used by providers and laboratories, it is important to monitor changes in test usage to help interpret reported trends in morbidity. We examined chlamydia testing data from one of the two largest commercial laboratories in the USA Methods Among chlamydia tests performed from June 2008—to July 2010 by this laboratory, we assessed the frequency of test types used by year, sex, specimen type, and positivity of these tests. Results During these 2 years, 2.9 million specimens were tested for chlamydia. Among those tested, 86% were women. Tests performed were: 77% NAATs, 23% DNA probes, and 0.3% cultures. Between year 1 and 2, NAATs increased from 73% to 80% of all tests, and DNA probes decreased from 27% to 19%. Test type varied by sex; 88% of tests among men were NAATs compared to 75% among women. The top specimen types among women tested by NAAT were: 45% cervical, 35% urine and 18% vaginal. Chlamydia positivity varied by test type: 5.1% NAAT, 1.4% DNA probe, and 2.3% culture. Conclusions NAATs were the most frequently used chlamydia test and their use increased over the evaluation period, creating a smaller market for other tests. Although vaginal swabs are the most sensitive specimen for testing women by NAAT, currently they are the least common specimen type used for testing. This may reflect the delayed introduction (FDA clearance) of the vaginal swab compared to other collection devices. Stocking the wide assortment of collection devices required for testing different specimens in different populations might also be a barrier for providers. Because these data are from one of the largest U.S. laboratories, with representation by insurance type and geography of the U.S. population, they can be useful for monitoring testing trends. Laboratory testing data also might be a valuable adjunct for national surveillance of chlamydia positivity trends that would not be dependent on provider or health department reporting nor small sample size from national surveys.

Objectives Partner concurrency is associated with STI acquisition, even when partners are sequential (ie, serial monogamy). However, little is known about the timing of STI relative to partner change. This is due, in part, to lack of documentation of STI before and after partner change. Using prospective behavioural and STI screening data, we compared the proportion of an STI occurring before and after partner change within a 12-week period. Methods As part of a larger study of risk and protective factors for STI in a mid-sized US city, young women provided weekly vaginal swabs and completed daily diaries of sexual behaviours for a 12-week period twice a year for up to 8 years. Vaginal swabs were tested for chlamydia (CT), gonorrhoea (NG) and trichomonas (TV) using amplified DNA-based tests. We limited analysis to the 12-week periods in which young women reported one sex partner change (ie, 2 sequential partners, no overlap). STIs with partner 1 were defined as those diagnosed before 1st sex with partner 2; STIs with partner 2 occurred after 1st sex with partner 2. Published data shows a higher odds of infection after a partner change (compared to no change) with the ORs ranging from 2.0 to over 4.0. We used a non-equivalency test to identify the odds for not detecting differences in STI acquired with partner 1 vs partner 2. If there is a difference between rates for partner 1 and partner 2, it will not be higher than the upper bound of the CI. Results Ninety-two women provided 111 12-week periods with one partner change. Mean age was 17.8 years; 94% were African American. Rates of STI were high for both Partner 1 and Partner 2 (see Abstract P1-S5.33 table 1). For CT, TV, and any STI, the upper bound of the 95% CI was lower previously reported rates. We have 95% confidence that the OR for infection with partner 2 vs partner one is not greater than 1.83 for CT, 1.47 for TV, and 1.68 for any STI. In contrast, the true OR for GC may fall within or higher than previously reported. We have 95% confidence that the OR for GC infection with partner 2 vs partner 1 is between 0 and 9.7. Conclusion Many young women already have an STI when a partner change occurs. These data suggest that the relationship contexts of partner change–in addition to the risk characteristics of a new partner–are also relevant to the epidemiology of STI in a specific common form of partner concurrency (ie, serial monogamy).

Objectives To assess the performance of the Roche fully automated cobas® 4800 CT/NG test for the detection of C trachomatis (CT) infection in clinical specimens compared to the current routine practice. Methods Consecutive clinical specimens sent to the Bacteriology department of the Bordeaux University Hospital, Bordeaux, between July and September 2010 were included. Results of the cobas® 4800 CT/NG test were compared with those obtained with the cobas® TaqMan CT 48 assay (Roche). For the latter, DNA from 200 μl of urine or swab resuspended in transport medium, (2SP or universal transport medium) was extracted on the MagNA Pure using the DNA I isolation kit (Roche) and amplified on the TaqMan 48 automates. The cobas® 4800 CT/NG performed DNA extraction from urine specimens prepared by adding 4.5 ml to 4.5 ml of cobas® PCR media, and from swabs discharged in 1.0 ml of the same media. The cobas® 4800 system loaded extracted DNA, controls and amplification reagents into 96-well amplification plates. Plates were then covered and placed into the cobas® z480 real-time PCR instrument. Retesting in both cobas® 4800 and TaqMan 48 assays was performed to further investigate specimens providing discrepant results. Results A total of 708 clinical specimens (293 male urines and 415 swab specimens, of which 356 self-collected vaginal swabs, 45 swabs from cervix and 14 swabs from male urethra) were analysed. The results were concordant in 98.5% of cases (697/708). Out of 708 samples, 50 provided positive results (17 men, 33 women). Three urine specimens and eight vaginal swabs provided discrepant results. Out of five specimens providing positive results in the reference CT assay, four were false-negative in the cobas® 4800 CT test. Out of six positive results by the cobas® 4800 assay, five were false-positive. After discrepancy analysis, the prevalence of the CT infection was 7.7% (55/708). The sensitivity and specificity of the cobas® 4800 CT/NG test were 92.7% (urine specimens 94.1%, swab specimens 92.1%) and 99.2%, respectively. The three false-negative results in swabs could be explained by the procedure not consistent with the manufacturer9s instructions. Indeed, swabs were not inserted directly into the cobas® media vials. Conclusion The cobas® 4800 CT/NG test is suitable for high through-put identification of the C trachomatis infection.

Over 17,000 high vaginal swabs are processed by the medical microbiology laboratory at the Royal Infirmary of Edinburgh each year. The majority of these high vaginal swabs are reported as negative. In most cases of positive results, the diagnosis could be made clinically (e.g. Candidiasis, Bacterial Vaginosis (BV)) and their presence does not indicate a sexually transmitted infection (STI). As such this represents a potentially significant waste of time and resources. All high vaginal swabs taken during the month of august in obstetric triage and assessment were examined for their clinical indication as well as their culture and treatment outcome. The results showed that as expected the majority of swabs were culture negative and only a minority of the culture positive swabs required treatment. Further analysis also revealed that while the majority of swabs taken were done so based on an appropriate clinical indication 18% of swabs were not. The most common indication quoted was abdominal pain with no signs or symptoms of infection evident or recorded. As all these swabs were culture negative they did indeed represent a waste of laboratory time and resources and as a result a formal guideline on indications for the use of high vaginal swabs was produced with the aim of reducing unnecessary investigations.

We would like to congratulate Skidmore et al 1 for providing data to validate self-collected samples (SCS) for the detection of chlamydia. No doubt their study was undertaken within a busy and limited resourced genitourinary medicine (GUM) clinic with little or no specific budget. They found that while there was a high (96%) concordance between specimens, SCS were significantly (12 vs 2, p = 0.004) more likely than endocervical samples to have unassessable results. As internal controls to assess the adequacy of collection of specimen were not reported, it was not possible to establish why unassessable results were more common in SCS. In general, studies show self-collected vaginal samples to have similar or lower numbers …

©FFPRHC J Fam Plann Reprod Health Care 2007: 33(4) Background Increasing publicity about sexually transmitted infections (STIs), in particular about screening young people for Chlamydia trachomatis (CT), is accompanied by some confusion about the various types of tests available including those done outside the usual health care settings (Box 1). At the present time, nucleic acid amplification tests (NAATs) are considered to be the most sensitive and specific tests available for CT testing and are considered to be the ‘gold standard’. In the UK, the Department of Health (DH) has provided funding for all National Health Service (NHS) laboratories to adopt these tests and the National Chlamydia Screening Programme (NCSP) stipulates that screening must be carried out using NAATs. The introduction of these tests has indeed facilitated screening by enabling the use of non-invasive samples (i.e. urine and self-taken vaginal swabs). However, in addition to these laboratory-based assays, there is debate about the role of more rapid tests and their suitability for home use.

Background HIV acquisition is facilitated by HSV-2 infection, making microbicides that block both viruses desirable for limiting HIV transmission. We have tested microbicides in a stringent efficacy model: vaginal co-challenge with a single high dose of SHIV-RT (10 3 TCID 50 ) and HSV-2 (2 × 10 8 pfu) in DepoProvera (DP)-treated macaques. Here we established a model mimicking real world exposure: repeated low dose SHIV/HSV-2 co-challenge in non-DP-treated animals. Methods Two groups of macaques were co-challenged weekly for 11wks with SHIV (10 or 50 TCID 50 ) and HSV-2 (10 7 pfu) after which the SHIV dose was increased to 200 TCID 50 in all animals for 9 more co-challenges. HSV-2 shedding in vaginal swabs and SHIV plasma viremia were determined. Antibodies (Abs) to SIV and HSV-2, HSV-2-specific T cell responses and the hormones estradiol and progesterone were measured in the blood. Results After 11 co-challenges, SHIV infections were detected in 1/3 animals from the 10 TCID 50 SHIV group and 1/3 from the 50 TCID 50 SHIV group (after 2 and 8 challenges, respectively). Upon increasing the SHIV dose, two more animals became infected (after 1 and 5 more co-challenges), but the last two remained uninfected. SHIV viremia was similar in all infected animals, which all developed SIV-specific Abs. All animals (6/6) became HSV-2 infected. Initial analyses suggest that the frequency of HSV-2 shedding was greater in non-DP-treated animals repeatedly exposed to 107 pfu than we previously observed for DP-treated animals that received a single 2 × 108 pfu dose of HSV-2 with SHIV (p Conclusion We have developed a repeated low dose co-challenge model to evaluate microbicides against SHIV and HSV-2. SHIV infection frequency was 67% in this model, similar to the single high dose co-challenge. HSV-2 infection was enhanced compared to the single high dose model.

Background The common asymptomatic nature of Chlamydia infections and consequential PIDs plus the delayed appearance of any damaging effect thereof on the reproductive tract hamper timely interventions for individuals prone to complications. In infertile women, Chlamydia antibodies in serum relate to tubal pathology and lower conception rates. The current ‘proof of principle study’ aimed to assess whether Chlamydia antibodies are detectable in easier, non-invasive vaginal mucosa samples, and if these could predict the risk for complications. Patients and Method We compared outcomes of Chlamydia antibody tests in serum and vaginal swabs in two groups: (a) 77 women attending a fertility clinic, of whom 25 tested positive for anti-chlamydia IgG in serum and (b) 107 women visiting an STI centre, including 30 Chlamydia PCR-positive subjects. The presence of IgG/IgA antibodies was compared (Kappa-test) and determinants investigated (regression). Results In women in the STI clinic, active Chlamydia infections were linked to both IgG and IgA antibodies in serum (p < 0.001) and IgA in vaginal mucosa (p < 0.001), but not IgG in mucosa; mucosa-IgA correlated with IgG in serum (p = 0.001). In women in the fertility clinic, IgG in vaginal mucosal material had a stronger correlation with IgG in serum (p = 0.02) than IgA in mucosa (p = 0.06). Women with tubal pathology or Chlamydia history more commonly had IgG in serum and IgA in vaginal mucosa (both p < 0.001), whereas this link was weaker for mucosa-IgG (p = 0.03); for tubal pathology alone mucosa-IgA had a higher Kappa than serum-IgG (0.41 versus 0.36). Discussion Chlamydia IgG/IgA are detectable in vaginal mucosal material. IgG antibodies in serum had stronger associations with current or past Chlamydia infections. However, IgA antibodies in vaginal mucosa also showed associations with (past) infection and complications. IgA presence in vaginal mucosa might indicate an on-going hidden Chlamydia infection in the upper genital tract, and warrants further epidemiological studies.

Chlamydia trachomatis (CT) infection spreads in Europe and in USA, and tendencies analysis shows an increase in the epidemic since last 10 years. In France, in 2006, a national survey carried out by phone and using a home-based sampling showed that CT prevalence was the highest in young people, with 3.6% for women and 2.4% in men aged 18–24 yo. To face this problem, several countries have developed new strategies, mixing newer technologies and home-based self-sampling test. Inspired by evaluation of those dispositives, the French National Institute of Health Prevention and Education (INPES) decided to experiment the proposition of a free home-based self-sampling to screen this infection via internet in young people 18–24 yo. This study, named Chlamyweb, aims to compare CT screening rate from this intervention with traditional information system and screening centre. Study design was a random control trial, with a 1:2 randomization. Recruitment took place on an Internet information website on sexually transmitted infections, and support by web campaign from September 3 to October 14 2012. Home-based kits were composed by uriswab 3 sponges for men and dry vaginal swabs for women (Copan diagnostics). All samples were analysed by using the fully automated cobas 4800 (Roche diagnostics). Self-sampling was proposed to 5 531 people. Out of them, 47.3% accepted, with a higher rate in women (53.0%). A total of 1616 kits provided [1002 from women (63.8%) and 614 from men (58.8%)] was return to the French National Reference Center for chlamydial infections. The global prevalence was 6.8% (8.3% in women, 4.4% in men). Sexual behaviour and sociodemographic patient’s characteristics were collected and their analysis is under investigation. These preliminary results show that Internet testing reaches a population with a high prevalence of CT infection and appears to be acceptable to young people.

Background TV is the most common curable STI worldwide and is associated with adverse consequences including preterm birth and acquisition/transmission of HIV. Yet, until recently, testing options for this infection were limited and had suboptimal sensitivity. Recently, nucleic acid amplification test systems (NAATS) for diagnosis of TV have been developed. Various types of specimens were studied in this process. We now report on the agreement of these specimen types for the diagnosis of TV using this NAATS assay. Methods Eight centres participated in this study. Specimens were collected from subjects presenting with symptoms of trichomoniasis or for routine visits. Specimens were collected in the following order: (1) first void urine, (2) patient-collected vaginal swab, (3) three clinician-collected vaginal swabs, (4) endocervical swab. Urine was aliquotted into a Viper neat and UPT tube for BD ProbeTec™ Trichomonas vaginalis (TV) Q x Amplified DNA Assay (TVQ) testing. The three clinician-collected vaginal swabs were used for wet mount, culture, and comparator testing. Sensitivity and specificity for the specimen types were calculated by comparing results to the patient infected status (PIS) algorithm of wet mount and TV culture. Results Results from 838 participants were available for evaluation. The overall prevalence of TV in this population was 120/838 (14.3%). Using the self-collected vaginal swab as the reference comparator, there was excellent agreement between vaginal swabs, neat and UPT urine, and endocervical swabs (kappa 0.93–0.95). Of these specimen types, endocervical had the lowest yield but still had excellent agreement with vaginal specimens. Conclusions Vaginal, urine, and endocervical samples showed excellent agreement for diagnosis of TV and are all acceptable specimens for use with the BD Viper™ System in extracted mode. The development of NAATS testing for TV, especially with the potential use of self-collected vaginal swab and urine specimens should greatly facilitate screening for this common STI.

Background Understanding patterns of human papillomavirus (HPV) infection in partnerships is essential in exploring transmission of HPV in sexual networks. Risk factors for HPV infection have yet to be explored at the dyad level. We studied features that predict presence of HPV in a new sexual partnership. Methods We analysed data from the HITCH Cohort Study of recently-formed couples. Women aged 18–24 attending university/college in Montreal, Canada and their male partners were recruited in 2006–10. Self-collected vaginal swabs and clinician-obtained swabs from the penis and scrotum were tested for DNA of 36 HPV types. We analysed baseline data from 479 couples. HPV in a partnership was defined as the presence of 1 or more HPV types in either or both partners. We used Poisson regression to calculate prevalence ratios with 95% confidence intervals for candidate risk factors. Results Most women were unvaccinated (88%). 67% of partnerships harboured HPV. For 49% both partners were HPV+. Detection was associated with the combined total of the male’s and female’s lifetime partners; from 27.5% among couples who jointly had no more than 4 partners to 94.2% among couples with > 20. Couples reporting concurrent partners were 2.8 times (95% CI 1.7–4.5) more likely to have HPV compared to those with a 12-month gap since the last extra-dyadic partner but this effect disappeared after adjustment for number of partners. Couples who always or frequently used condoms with their previous partner(s) were 29% (95% CI 9–45%) less likely to have HPV after accounting for number of partners and gap length/concurrency. Conclusions Number of extra-dyadic partners (past or concurrent) predicts the likelihood of HPV in a partnership. Condoms may have some impact on limiting spread of HPV, although protection was incomplete. Epidemiologic monitoring of HPV in sexual networks is needed, particularly in populations with suboptimal HPV vaccine coverage.

Background Trichomonas vaginalis (TV) infection is a prevalent parasitic STD that may increase the risk of acquiring other STI including HIV. Trichomoniasis has been increasingly reported in older female populations. Detection methods include the InPouch culture system and GenProbe’s APTIMA Trichomonas vaginalis nucleic acid amplification test (NAAT). Both systems detect TV (viable or genetic material, respectively) from vaginal swabs. In addition to comparing TV detection technologies, this study attempted to look at infection status in younger versus older macaque populations. Methods 24 sexually mature female pigtailed macaques were challenged with TV (ATCC 50148, human isolate), and followed weekly for five weeks, before metronidazole treatment. The reproductive age span for pigtailed macaques is approximately 4 to 18 years of age. Twelve animals aged 4–7 and twelve animals older than 13 years were enrolled. Paired vaginal swabs were collected weekly from each animal for culture and NAAT detection assays. Results Each TV-challenged macaque developed trichomoniasis. Of 199 matched samples (culture and NAAT), 13 had discrepant results. Six of these were likely due to false culture results. Four samples represented the transition time from positive to negative status in three animals. It is plausible that organisms detected by NAAT were no longer viable (thus culture-negative). There is no obvious explanation for the three remaining discrepant results. Trichomoniasis infection was self-limited (resolved prior to metronidazole treatment) in eight animals: two older and six younger macaques. Two of these younger macaques experienced intermittent discrepant results after testing negative by both methods for two consecutive weeks. Conclusions NAAT detection appears to be more sensitive and less prone to erroneous results in this laboratory’s experience. There may be a trend for younger animals to self-clear TV infection faster than older animals, which might explain the increased TVinfection rates noted in older women.

Background Chlamydia trachomatis and Neisseria gonorrhoeae are among the most common causes of sexually transmitted bacterial infections worldwide. Infection with these organisms is mostly asymptomatic, however serious complications are also observed. Screening of the diseases is necessary to identify, treat and control the infection. In this study, we evaluated the performance of the triplex real-time PCR assay with internal control for detection of C. trachomatis and N. gonorrhoeae infections in urine and vaginal swabs. Methods The performance of TaqMan probe-based triplex real time PCR targeting the cryptic plasmids of C. trachomatis (pCHL1) and N. gonorrhoeae (pJD1) and beta-globin gene as an internal control was assessed using 188 urine specimens and 118 vaginal swabs. The triplex real time PCR was compared with the Roche COBAS AMPLICOR CT/NG assay. The urine specimens were further tested using real-time PCR targeting the N. gonorrhoeae porA pseudogene. Results For urine specimens, the sensitivity and specificity of the triplex real time PCR were 100% and 97.6%, respectively, for C. trachomatis, and 100% and 95.2%, respectively, for N. gonorrhoeae. For vaginal swabs, the sensitivity and specificity were 100% and 100%, respectively, for C. trachomatis, and 100% and 98.1%, respectively, for N. gonorrhoeae. There were 5 (2.84%) from 176 urine specimens that were negative for cryptic plasmid, but positive for N. gonorrhoeae porA pseudogene. Conclusion The performance of the triplex real time PCR assay was comparable to that of the Roche COBAS AMPLICOR CT/NG assay. This assay is easy to perform and the results can be achieved in 3–4 hours, including sample preparation. The estimated cost of triplex real time PCR was less than 20 USD. Taken together with using non-invasive urine sampling, this assay is convenient and suitable for epidemiological studies in screening large number of samples.

Background The BD ProbeTecTMTrichomonas vaginalis (TV) Qx amplified DNA Assay (TVQ) is a new test for qualitative detection of TV DNA that can be performed on the automated BD Viper System. The objective of this study was to compare the performance of this new assay to a patient infected status (PIS) and to an FDA approved molecular assay using vaginal swabs. Methods Vaginal swabs were obtained from women attending STD or family planning clinics at 7 sites. A patient collected vaginal swab was tested by TVQ; APTIMA TV (ATV) testing was performed using a clinician obtained vaginal swab according to the package insert. Additional clinician obtained vaginal swabs were used for wet mount and culture. A patient was considered infected if either the wet mount or culture was positive for TV and not infected if both tests were negative. Agreement between the TVQ and ATV assays was assessed using Kappa statistics. Results Data were available for TVQ evaluation from 838 women, 116 of whom were defined as infected with TV. Despite being in the definition of the PIS, wet mount still had a sensitivity of only 68.7% which was statistically lower than the other assays (p Conclusions The TVQ assay performed significantly better than wet mount and had comparable sensitivity and specificity to an FDA approved molecular assay for the detection of TV. This study provides additional evidence of the poor performance of wet mount for TV. The use of patient collected vaginal swabs for the detection of TV DNA provides clinicians with the opportunity to increase efficiency within the clinic while obtaining improved results over wet mount.

Introduction Recent data have raised questions over the efficacy of azithromycin 1g for the treatment of chlamydia infection. In order to measure effective absorption, we developed a protocol to quantify the concentration of azithromycin using liquid chromatography and tandem mass spectrometry (LC-MS/MS) in self-collected high-vaginal swabs. Methods Ten healthy women were asked to self-collect a high-vaginal swab (baseline) prior to taking a 1g dose of azithromycin. A blood sample was collected four hours later to determine plasma concentrations of azithromycin. Participants then self-collected a high vaginal swab each day for a further 9 days. All swabs were preserved in 1ml of 100% Methanol and stored at –80°C prior to analysis. One ml of chloroform containing 10mg/ml of Leucine enkephalin as an internal standard was added to extract azithromycin. Azithromycin concentrations were calculated using a validated LC-MS/MS method. Data were normalised to the internal standard and to membrane lipid concentrations, measured in the same samples using LC-MS/MS. Results Azithromycin was detected at varying concentrations in all 10 women in all post-treatment samples. The highest average normalised azithromycin concentration of 953ng/ml (range = 267–2200ng/ml, standard error of mean (sem) = 181ng/ml) was detected on day 2 post-treatment. The lowest average azithromycin concentration was 164ng/ml (range = 51–387ng/ml, sem = 42ng/ml), 9 days post-treatment. The average concentration of azithromycin detected in blood samples was 339ng/ml (range = 107–628ng/ml, sem = 57ng/ml). In 9/10 women azithromycin concentrations remained above 64ng/ml, the hypothesised mean inhibitory concentration (MIC) of azithromycin for chlamydia, for the entire 9 days. Conclusion We have validated a method for detecting the azithromycin concentration in self-collected high-vaginal samples using LC-MS/MS. Azithromycin concentrations remained above the reported MIC of 64ng/ml for up to 9 days post-treatment in high-vaginal swabs from 10 healthy women.

Background Trichomonas vaginalis (TV) is a sexually transmitted organism associated with vaginitis, cervicitis, urethritis, low birth weight, preterm delivery, pelvic inflammatory disease and HIV transmission and acquisition. Nucleic acid amplification testing improves the sensitivity for detection of pathogens. The performance of the BD ProbeTec™ TV Qx (TVQ) Amplified DNA Assay and the Gen-Probe Aptima TV assay were compared to patient infected status (PIS) established by the InPouch TV culture and wet mount for the detection of trichomonas in women. Methods Participants with symptoms of trichomonas or presenting for routine visit were enrolled from seven geographically diverse centres. First void urine, a patient collected vaginal swab, and three clinician-collected vaginal swabs were obtained from each participant. Urine was aliquoted into BD neat and UPT tubes as well as an Aptima UTT tube. The first two clinician-collected vaginal swabs were randomised for wet mount and InPouch TV culture. The third was used for the Aptima TV assay. Results There were a total of 1034 compliant participants with evaluable PIS. Specimen and instrument level exclusions resulted in 830 compliant vaginal result sets and 733 neat, UPT and UTT urine result sets for evaluation. For vaginal specimens, the sensitivity (specificity) of the TVQ Assay and the Aptima TV Assay compared to PIS were 98.3% (99%) and 100% (98.3%), respectively. For BD neat and UPT urine specimens, the sensitivity (specificity) of the TVQ Assay compared to PIS were 95.5% (98.7%) and 94.6% (98.6%). For the Aptima UTT urine specimen, the sensitivity and specificity of the Aptima TV Assay compared to PIS were 97.3% and 98.7%. Conclusion The BD ProbeTec™ Trichomonas vaginalis Q x Amplified DNA Assay on the BD Viper™ System in extracted mode demonstrated excellent performance characteristics that were comparable to the only commercially available nucleic acid amplification assay for the detection of Trichomonas vaginalis.

At the Bordeaux University Hospital, among pregnant women aged less than 25 years-old the prevalence of C. trachomatis (CT) and N. gonorrhoeae (NG) is 12.5% and 2.4%, respectively for those requesting abortion by using the Abbott m2000 CT/NG test, and 7.9% and 0%, respectively, for those consulting for monitoring pregnancy by using the Roche Cobas 4800 CT/NG test. The objective of this study was to evaluate and compare the performances of both of these tests along with a third one, the Cepheid GeneXpert CT/NG, for the detection of CT and NG in vaginal swabs collected from pregnant women consulting for abortion or for monitoring pregnancy. A patient was considered infected if at least two tests were positive. Among 304 pregnant women included, from September 2012 to January 2013, 34 were infected, leading a prevalence of 11.7% (26/222) for patients requesting abortion and 9.7% (8/82) for patients consulting for monitoring pregnancy. There were two false CT-positive results with the Abbott m2000, one false negative result reported by Roche and the Cepheid GeneXpert. The sensitivity and specificity were 97% and 100% for the Roche and the Cepheid GeneXpert tests, and 100% and 99.3% for the Abbott assay. The positive predictive value ranged from 94.4% to 100% according to the test. For NG, 297 specimens were negative and 7 were positive using the three tests. All results were concordant, leading to a sensitivity and specificity of 100% for all the assays. The prevalence of NG among pregnant women requesting abortion was 2.7% (6/222) and 1.2% (1/82) for those consulting for monitoring pregnancy. In the populations studied, all three assays have similar performances for CT/NG detection.

Background Lactobacillus is an integral part of vaginal microbiota that maintains healthy environment and plays an important role in preventing sexually transmitted infections and HIV. We profile the Lactobacillus species present when the women are healthy or have Bacterial Vaginosis among women in US and India. Method Between February 2010 and November 2011, a sample of 75 women attending Prerana Women’s Health Clinic in India or San Francisco City Clinic in USA were sampled and diagnosed for BV based on Amsel’s Criteria. In addition, Gram stained smears of vaginal fluid were Nugent scored. Vaginal swabs were then cultured in MRS broth. Gram positive Lactobacilli generating about 600–800bp amplicon by16SrDNA PCR with 16S primers were further characterised by sequencing. Result Vaginal samples were obtained from 75 women. According to Amsel criteria, 34 women were healthy and 41 women had BV. Lactobacilli were isolated from 22 healthy Indian and 10 healthy US women. Lactobacilli were also isolated from 4 Indian and 5 US women with BV. Eleven Lactobacillus species were isolated from 26 Indian women and 9 species were identified from 15 US women. The common Lactobacilli species found in Indian women included L. Crispatus (24.3%), L. Gasseri (24.3%), and L. Jensenii (13.5%), while L. Crispatus (32.0%), L. Jensenii (20.0%), and L. Coleohominis (12.0%) were common in US women. L. crispatus was cultured from 44% of healthy and 4.9% of women with BV. L. jensenii , L. gasseri , and L. acidophilus were cultured from 25.6%, 23.5% and 2.9% of healthy women; and 2.4%, 4.9% and 0.0% of BV women, respectively. Conclusion Our findings showed lactobacilli species present in healthy vagina of women in India do not differ from those reported from other countries. This information is useful to development of microbicides for HIV prevention.

Background Culturally, women are less inclined to undergo a per-speculum examination for screening of reproductive tract infections and consider self-sampling more acceptable. This study examines the concordance between Gram stains of vaginal smears and pH obtained by clinician conducted speculum examination with similar smears and pH prepared from self-collected vaginal swabs. Methods Between June 2010 and 2012, self-collected (SVS) and clinician-collected vaginal (CVS) swabs were obtained from 79 young reproductive age women attending the Prerana Reproductive Health Clinic in Mysore, India. The study was explained to each participant and a brochure illustrating how to collect vaginal swabs was handed to them. The Gram-stained smears and saline wet mounts prepared from the SVS and CVS were examined by a trained microbiologist and the clinician. Vaginal pH was recorded for each swab. Kappa coefficient was used to quantify agreement between the two sets of results. Results When compared with the CVS, the ability of the self-obtained Gram stain to diagnose bacterial vaginosis had a sensitivity of 100%, specificity of 98%, positive predictive value of 100% and negative predictive value of 100%. Only one pair was discordant in the results where the SVS showed the BV status as negative while the CVS found it to be intermediate stage BV. There was substantial agreement (kappa = 0.97) between the two collection methods in the ability to determine the grade of vaginal flora. Conclusion As compared with clinician collected vaginal smears, self-collected smears have substantial agreement in the diagnosis of bacterial vaginosis. With adequate education and instructions using simple visual illustrations, it is possible to have women sample and self collect vaginal swabs for diagnosis of lower genital tract infections.

Introduction Fetal fibronectin (fFN) is an excellent predictor of preterm birth. Seminal fluid may cross react with the fFN assay. Sexual intercourse on quantitatively measured concentration of fetal fibronectin (fFN) in vaginal swabs from women who have had sexual intercourse has not previously been analysed. Method Prospectively collected data from 78 women at risk of preterm birth (with ethics/consent) who had quantitative fetal fibronectin testing at the Preterm Surveillance Clinic in St Thomas9 Hospital, London, was performed. 39 women with sexual intercourse within 48 hours of testing were compared with 39 controls, matched by previous history, gestational age and delivery outcome. Data was blinded so concentrations were not revealed until after delivery. Results The mean concentration of fFN in women who had sexual intercourse in the previous 48 hours was 132.1 ng/ml (STD = 171.2) compared to a mean concentration of 9.7 ng/ml (STD = 18.6) in the control group, (p value =0.00004). 17 women had false positive tests in the sexual intercourse group (50ng/ml; 37/40 gestation), compared with 2 in the control group. Conclusion The concentration of fFN was significantly higher in women who had sexual intercourse in the previous 48 hours compared to women who didn9t. Sexual intercourse increases the risk of false-positive fFN test. A history of vaginal sexual intercourse should be obtained from women prior to sampling.

Background Culture of Neisseria gonorrhoeae from the urethral and endocervix is currently the recommended method of detecting gonorrhoea (GC) in women in the UK. This necessitates a speculum examination. NAATs are the mainstay of testing for Chlamydia trachomatis (CT) infection and assays exist which can also detect GC. NAATs are more sensitive than culture meaning non-invasive samples can be used. No previous study has compared self-taken VVS analysed by AC2 with urethral and endocervical GC culture, which is considered the gold standard test in the UK. We therefore undertook this comparison in a clinical setting with low GC prevalence and performed a cost-effectiveness analysis. Methods Participants were recruited within the Centre for Sexual Health at Leeds, UK between March 2009 and January 2010. The women, presenting for a new visit, performed a self-taken VVS and were then examined and urethral and endocervical samples taken for GC culture. Positive AC2 tests were confirmed by the Aptima GC and/or Aptima CT mono-specific platform tests. The cost effectiveness was analysed using incremental cost effectiveness ratios (ICERs). The analysis uses correct detection of GC as the primary endpoint and adopts the perspective of the UK National Health Service. Costs were estimated from a sub-sample of 92 patients in July 2009. The analysis includes costs of clinic time, together with the laboratory costs. Comparisons were made of self-taken VVSs using AC2 vs clinician taken cultures for the whole cohort. Results 100 of the 3973 participants (2.5%) were infected with GC. The overall sensitivity of GC culture was 82% and self-taken VVS 95%. 35% of the participants were asymptomatic in whom GC culture sensitivity was 79% and self-taken VVS 91%. The cost effectiveness results are presented in Abstract P3-S1.24 table 1. Conclusions Self-taken VVS analysed by AC2 are cost effective compared to urethral and endocervical GC culture; being more sensitive and less costly. Whilst those presenting with symptoms continue to require a clinician examination use of VVSs in women with no symptoms removes the need for examination. The cost of the time taken in explanation of self taken swabs for this group represents

Background Vaginal swabs are an optimal specimen for detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). The Gen-Probe Aptima system (Aptima) requires use of a sample transport media, whereas the Becton Dickinson ProbeTec ET System (Probetec) can utilise dry swabs. The use of dry swabs allows for collection of STD test samples at non-clinical testing venues. Methods Swabs were collected from 180 sexually active women aged 15–25 years, who had asymptomatic BV and two or more risk factors for STDs. The participants received home vaginal swab self-collection kits for BV and STD testing. Participants mailed the kits directly to the lab. Probetec swabs were tested within 14 days of collection. A dry transport swab was placed into an Aptima vaginal swab collection tube, generally within 14 days of collection and stored at −80°C. Aptima swabs were thawed and tested in batches. Specimens with discordant results in the two nucleic acid amplification test systems were retested with both systems. Results There were 58 women (32%) positive for GC and 62 (34%) positive for CT. The level of agreement between the Aptima and Probetec systems was higher for CT (176/180, 98%) than for GC (171/180, 95%). Of the 13 samples with discordant results, five were resolved with repeat testing. All eight remaining samples had discordant GC results: seven were Probetec positive, Aptima negative and one was Probetec negative, Aptima positive. Conclusions Vaginal swabs tested in the Aptima system were equivalent to Probetec in detecting CT but were less sensitive for the detection of GC. Dry swabs cannot be recommended for detection of GC from vaginal swabs using the Aptima system.

Background Bacterial vaginosis (BV) remains the most common cause of abnormal vaginal discharge in Indian women of reproductive age and is associated with increased susceptibility to HIV/STI and preterm delivery. Diagnosis of BV in resource-poor settings is often overlooked; there is a need for cheap, rapid, objective point-of-care diagnostic test. Methods Vaginal swabs were collected from women attending a women9s health clinic. Women over the age of 18 with a pH of over 4.5 were invited to participate in the study. BV was diagnosed on the basis of the Nugent score, the Amsel clinical criteria, and results of OSOM BVBlue test independently by study clinician and laboratory personnel who were blinded to the results of the other tests. Results From August 2009 to May 2010, 313 participants were enrolled. BV prevalence was 45.1% (95% CI 41.5% to 52.8%) according to Nugent score. When compared with the Nugent score, the sensitivity, specificity, positive predictive value, negative predictive value for Amsel clinical criteria was 61.9%, 88.3%, 81.5%, 73.7%; and for BVBlue it was 38.1%, 92.7%, 82.1%, 63.9% respectively. The performance of BVBlue can be increased if it is combined with “Whiff test where the sensitivity increases to 64.4%, sensitivity 85.6%, PPV 79.3% and NPV 73.8%”. Conclusions These results highlight the importance of systematic evaluation of rapid test kits as a low-cost alternative to laboratory diagnosis in resource-constrained settings. The BVBlue test is a simple, rapid, and objective test for the diagnosis of BV and has the potential to facilitate prompt diagnosis and appropriate treatment of BV in the absence of microscopy.

Background The Roche cobas 4800 (cobas) is a new diagnostic assay that utilises an automated workstation to isolate nucleic acids from clinical specimens and a real time instrument for the detection of C trachomatis (CT) and N gonorrhoeae (NG). The objective of this study was to compare the performance characteristics of the cobas to the BD Viper (Viper) and GenProbe Aptima Combo 2 (AC2) assays for the detection of CT and NG using a patient infected standard (PIS). Methods Specimens were obtained from women attending STD, family planning, or OB/GYN clinics from 12 geographically distinct locations. Urine and vaginal swabs were obtained from each participant as were endocervical (data not shown) and liquid based cytology samples (data not shown). Women were randomised to either self-obtained (SOV) or clinician-obtained (COV) vaginal swab collection. Four sites performed testing by AC2, cobas, and Viper for urine and by cobas for vaginal swabs. A patient was considered infected if at least two of the assays with different molecular targets gave positive results from cervical or urine samples. Results Overall CT sensitivity ranged from 91.9% to 93.9% and specificity ranged from 99.7% to 99.8% for all sample types. Overall GC sensitivity ranged from 97.0% to 100% and specificity from 99.9% to 100% see Abstract P3-S1.33 table 1. Conclusions The cobas assay has excellent sensitivity and specificity when compared to PIS. There was no difference in performance between the SOV and COV specimens or between the vaginal and urine specimens. Self-obtained vaginal swabs provide opportunities for increased efficiency within the clinical settings. The assay is easy to perform, automated, and can be completed in

Background To study the prevalence of genital chlamydia and gonococcal infections in women at risk of acquiring sexually transmitted infections in the Kumasi metropolis, Ghana. Methods Structured interviews and clinical examination of participants aged between 18 and 35 years (inclusive) were carried out. Other inclusive criteria were having at least three sexual acts per week and having had at least two sexual partners in the preceding 3 months. Vaginal swabs were also obtained to test for gonorrhoea and chlamydia infections. Results One thousand and seventy women participated in the study. Genital chlamydia infection was found in 4.8% of participants whilst gonococcal infection was found in 0.9% of participants. Conclusion The prevalence of genital chlamydia and gonococcal infections was low in these at-risk women. The prevalence is also lower than reported in other female populations in the country.

Background Affordable and reliable point of care (POC) tests to diagnose urogenital chlamydia infections (POC-Ct) are needed, especially in resource limited settings. WHO has formulated standards that POC tests have to meet. One of those is that the test should be sensitive. Three POC-Ct tests currently on the market all showed poor sensitivity between 12% and 17% in a non-manufacturer sponsored clinical study (van Dommelen 2010). One POC-Ct test evaluated in a manufacturer-sponsored study claims over 80% sensitivity (Mahilum-Tapay 2007). We evaluated the performance of this POC-Ct in two outpatient clinics in Suriname, S.A. Methods Between July 2009 and February 2010 963 women were included in a high risk STI clinic (n=181) and a low risk birth control clinic (n=782) in Paramaribo, Suriname. Nurse collected vaginal swabs were obtained for the POC-Ct (Diagnostics for the Real World, LTD, Cambridge, UK) and control NAAT (APTIMA Combo 2, Gen-Probe, San Diego, USA) in a cross-over model. Swabs were processed according to the manufacturers instructions. POC-Ct was compared to NAAT and sensitivity, specificity, positive- and negative predictive value (PPV, NPV) were calculated. Quantitative Ct load was determined with a real-time PCR targeting the cryptic plasmid. Ct load was expressed as inclusion forming units (IFU) based on defined serial dilutions. An independent t-test was used to compare log-transformed Ct loads between true positive and false negative POC-Ct results. Results Ct prevalence, determined by NAAT, was 23% at the high risk STI clinic and 9% at the low risk birth control clinic. Four samples were excluded due to discrepancy in POC-Ct result between two lab technicians (n=3) and failure of POC-Ct (n=1). Performance results of POC-Ct compared to NAAT are shown in Abstract P3-S1.26 table 1. Quantitative Ct bacterial load was 65 times higher when POC-Ct detected Ct infection (geometric mean 115 IFU) compared to loads that POC-Ct did not detect (geometric mean 1.8 IFU, p Conclusion The sensitivity and to a lesser extend the PPV of the POC-Ct did not meet the expectations as described previously (83.5%). The POC-Ct missed samples with a low Ct load. With a sensitivity of 41.7% the Diagnostics of the Real World POC-Ct test does not meet the ASSURED criteria of a sensitive test formulated by the WHO.

Background Surveillance of Gonorrhoea resistance is a public health priority. At the Rotterdam STI clinic diagnostic tests for gonorrhoea are done by NAAT techniques from urine in men, and (self taken) vaginal swabs in women. For the purpose of resistance monitoring confirmation by culture is performed from urethra in men and cervix in women. In this study we evaluated whether culture is possible from vaginal swab, and whether women could perform this by self taken vaginal swabs. Methods Gonorrhoea diagnostic is performed by SDA technique (BD-USA). For Culture swabs are put on GC-lect agar plates and incubated overnight at 30°C in CO 2 atmosphere. The next day transport to the laboratory is done in CO 2 jars. Cultures are examined for a maximum of 72 h. (Presumed) Positive cultures are identified by AccuProbe (BioMerieux-France). In phase 1 culture in female patients was performed by a health care provider by cervical swabs, in phase 2 by cervical and vaginal swab, in phase 3 a vaginal swab by the patient was added. Results In Phase 1, 8/26 (31%) cervical cultures showed growth of gonorrhoea, 18 were negative. Mean time between PCR and culture was 18 days in positive and negative cases. In Phase 2, 21 women were cultured cervically and vaginally; 6/21 (29%) showed growth of gonorrhoea without discrepancies between the sites. In 17 women only vaginal swabs were taken, of whom 29% positive in culture. Mean time between PCR and culture was 20 days in positive and negative cases. In phase 3, seven women were cultured three times. 2/7 cultures (29%) were positive cervically and vaginally (professional and patient swab). The five other cases were all negative. Conclusions Confirmation of vaginal gonorrhoea infection by culture was only achieved in 30% despite optimal laboratory methods. Gonococci can be grown from vaginal swabs, and no discrepancy was found between health care provider and patient taken swabs. Cultures taken for surveillance of resistance can be taken by women themselves without having to undergo physical examination.

Objectives Chlamydia trachomatis (CT) and Neisseria gonnorhoea (NG) are the most prevalent sexual transmitted diseases worldwide. In recent years molecular diagnostics for the standard sample types like cervical swabs and urines has been highly adapted in most laboratories. Currently more difficult samples types, with regard to inhibition, sensitivity and specificity, like rectal swabs and (self collected) vaginal swabs are received more often in the laboratories. This study describes the performance of the new Cobas 4800 for the detection of CT and NG in these difficult sample types. Methods A total of 1100 co-collected swabs were tested (900 vaginal; 200 rectal). Informed consent was obtained from all patients included in the study for co-collection. All swabs were tested routinely with the M2000 system (Abbott) and the co-collected samples were tested in the Cobas 4800 system (Roche). All swabs were collected in their corresponding transport buffer and tested blinded. Discrepant results were tested with an independent real time PCR method. Results In the 900 vaginal swabs 10% (n=90) were positive for CT and 0.5% (n=4) for NG and in the 200 rectal swabs 11% CT positives (n=22) an 6% NG positives (n=12) were identified. In the vaginal samples nine discrepant results between the Cobas 4800 and M2000 system were identified. Five with borderline values and four with clear different results (1 NG, 3CT). Two M2000 positive results (Ct 35.9; 32.3) were available for home brew analysis and could not be confirmed. In the rectal samples 8 discrepant results were found including three clear differences (2 NG; 1 CT). The CT discrepant sample was positive in the Cobas 4800 system (Cp 33.1) and negative in the M2000 system. For NG two samples were negative in the Cobas 4800 system but positive (Ct 23.8; 32.0) in the M2000 system. All three clear discrepant results were available for home brew analysis and confirmed the Cobas 4800 results. Conclusion Both samples types showed a high concordance between the two systems (ĸ 0.95 for CT; ĸ 0.93 for NG). For detection of vaginal swabs some small differences were found both for CT and NG but these were equally spread between the two systems. There is no difference between self collected and clinician taken vaginal swabs. All clear rectal swabs discrepancies confirmed the Cobas 4800 results. This remarkable difference has to be further studied. In general, (self collected) vaginal swabs and rectal swabs show reliable results for routine detection of CT and NG.

Background There have been few studies of the sexual transmission of human papillomavirus (HPV) between partners. Our objective was to estimate transmission rates among persons with documented sexual exposure to an infected partner and longitudinal follow-up. Methods We analysed data from the HITCH Cohort Study, a study of recently-formed couples. Women aged 18–24 attending a university or junior college in Montreal, Canada and their male partners were eligible. Self-collected vaginal swabs and clinician-obtained swabs of epithelial cells from the penis and scrotum were tested for DNA of 36 HPV types. We analysed follow-up data at visit 2 from 179 couples who were discordant for one or more HPV types at enrolment. We defined the index partner as that which was infected with a type(s) not found in the other partner, and a transmission event as subsequent detection of that HPV type in the non-index partner. Transmission rates are expressed as the number of transmissions per 100 person-months (PM), with 95% CI estimated using Poisson regression. Results Transmission was observed in 73 partnerships. There was little difference between the male-to-female (3.5 per 100PM, 95% CI 2.7 to 4.5) and the female-to-male transmission rate (4.0 per 100PM, 95% CI 3.0 to 5.5). These rates are consistent with a per-partnership transmission probability of 0.20 (95% CI 0.16 to 0.24) over 6 months. Transmission rates did not differ with the lifetime number of partners reported by the non-index partner at enrolment or with the circumcision status of the male partner. Rates were highest when the index partner was still positive for that type at follow-up; rates of male-to-female transmission quadrupled and female-to-male transmission tripled (5.2 and 6.2 per 100PM, respectively), compared to when the index partner was negative at follow-up (1.2 and 1.8 per 100PM, respectively, p Conclusions Transmission rates based on follow-up of discordant partners are probably underestimates of the true rate due to clearance in index partner and the depletion of susceptibles. Our results contribute to a small but growing evidence base regarding the natural history of HPV transmission and the probability of transmission. These estimates may be of utility to improve forecasting estimates from mathematical modelling efforts to project the public health impact and cost-effectiveness of HPV vaccination.