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Background Young people living in remote Aboriginal communities experience some of the highest rates of chlamydia (CT) and gonorrhoea (NG) infection globally. A cluster-randomised controlled trial (TTANGO) in 11 remote primary health services demonstrated point-of-care (POC) testing for CT/NG was acceptable, accurate, improved the uptake and timeliness of treatment, and was cost-saving. Subsequently, POC testing was scaled-up and implemented in a further 20 remote health services (TTANGO2 program) across four jurisdictions (31 in total). We determine whether the uptake of POC testing observed in the trial was also achieved and sustained during the long-term program. Methods We conducted descriptive, interrupted time series and trajectory analyses to compare POC testing patterns over two time periods (trial: 2013–15 and program: 2016–19). For the trajectory analysis, we applied a Poisson model to identify and fit health services to testing groups. Results Among the 11 services who participated in both the trial and program, 7871 tests were conducted in total. The median number of tests per month in the trial was 241(IQR:178–305) and 408(IQR:294–538) in the program, with no significant trend in the trial (5.6 tests per month, p=0.190) but a significant increasing trend in the program (10.52 tests per month, p Conclusions Our findings suggest POC testing can be scaled-up and sustained as part of a routinely implemented program, achieving greater than expected testing numbers to support the clinical and public health benefits of more timely treatment. Further research is underway to investigate barriers among the ‘low’ testing sites. These findings support the proposed transition from syndromic management towards aetiological diagnosis and treatment in low- and middle-income countries.

Background HIV self-testing was proved as an effective tool for increasing testing frequency in gay and bisexual men at high risk of infection. Questions remain about understanding why HIVST encouraged testing and how such success can be translated to programmatic implementation. Methods We conducted a qualitative investigation of how FORTH participants experienced and perceived HIVST. Stratified sampling was used to recruit gay and bisexual men participating in the FORTH HIVST intervention to take part in interviews, focusing on infrequent testers and those who had received inaccurate HIVST results. Results Our analysis identified several prominent themes organized into two overarching domains from the 15 interviews: (i) aspects of HIVST contributing to HIV testing frequency, and (ii) sustaining HIVST into the future. Participants also believed that their use of HIVST in the future would depend on the test kit’s reliability, particularly when compared with highly reliable clinic-based testing. Conclusion HIVST increases the frequency of HIV testing among gay and bisexual men due, in part, to the practical, psychological, and social benefits it offers. To capitalize fully on these benefits, however, strategies to ensure the availability of highly reliable HIVST are required to sustain benefits beyond the confines of a structured research study.

Background: A wait-list randomised controlled trial in Australia (FORTH) in high-risk gay and bisexual men (GBM) showed access to free HIV self-tests (HIVSTs) doubled the frequency of HIV testing in year 1 to reach guideline recommended levels of 4 tests per year, compared to two tests per year in the standard-care arm (facility-based testing). In year 2, men in both arms had access to HIVSTs. We assessed if the effect was maintained for a further 12 months. Methods:: Participants included GBM reporting condomless anal intercourse or > 5 male partners in the past 3 months. We included men who had completed at least one survey in both year 1 and 2 and calculated the mean tests per person, based on the validated self-report and clinic records. We used Poisson regression and random effects Poisson regression models to compare the overall testing frequency by study arm, year and testing modality (HIVST/facility-based test). Findings:: Overall, 362 men completed at least one survey in year 1 and 343 in year 2. Among men in the intervention arm (access to HIVSTs in both years), the mean number of HIV tests in year 2 (3⋅7 overall, 2⋅3 facility-based tests, 1⋅4 HIVSTs) was lower compared to year 1 (4⋅1 overall, 1⋅7 facility-based tests, 2⋅4 HIVSTs) (RR:0⋅84, 95% CI:0⋅75-0⋅95, p=0⋅002), but higher than the standard-care arm in year 1 (2⋅0 overall, RR:1⋅71, 95% CI:1⋅48-1.97, p

Repeat chlamydia detection after treatment is common, and there is concern that treatment failure may be a cause.Within a randomized trial, we established a prospective cohort of 600 participants with anogenital chlamydia diagnoses (200 each of women, heterosexual men, and men who have sex with men [MSM]). Participants were invited for repeat testing at 3 months and to complete a behavioral survey at 4 months. Positive samples were analyzed for organism DNA load and genovar. We estimated repeat chlamydia positivity, reinfection and treatment failure rates, and investigated the biological and behavioral factors associated with a repeat positive test.A total of 290 participants (100 women, 89 heterosexual men, 101 MSM) were retested at 1 to 4 months, with 43 repeat positives, including 26 classed as reinfection and 9 as treatment failures. Comparing MSM with heterosexual men and women combined, repeat positivity was higher (20.8% vs 11.6%, P = 0.04), and treatment failure was higher (6.9% vs 1.1%, P = 0.01), but there was no difference in reinfection rates (11.9% vs 7.4%, P = 0.21). Among MSM, the odds of repeat positivity increased by 90% with each additional log organism load in the original specimen (baseline) (adjusted odds ratio, 1.9; 95% confidence interval, 1.1-3.2). Among heterosexuals, the odds of repeat positivity decreased by 10% with each additional week delay in being retested for chlamydia (adjusted odds ratio, 0.9; 95% confidence interval, 0.8-0.9).Positive retests were more common among MSM than heterosexuals. Treatment failure was more common in MSM with rectal chlamydia, reinforcing concerns about azithromycin treatment failure.

Introduction Chlamydia retesting 3 months after treatment is recommended to detect reinfections, but retesting rates are typically low. The purpose of this study is to determine if the addition of a postal home collection kit to a short message service (SMS) reminder at 3 months increases the percentage of patients retested for chlamydia at 1–4 months, compared to SMS alone. Design In this unblinded randomized controlled trial, participants were randomized 1:1 to intervention (home arm) or control (clinic arm) status. Setting/participants Participants included 200 each of women, heterosexual men, and men who have sex with men diagnosed and treated for chlamydia at sexual health services. Intervention Three months after chlamydia diagnosis, home arm participants received an SMS reminder and postal home collection kit (women, vaginal swab; heterosexual men, Copan UriSwab; men who have sex with men, UriSwab and rectal swab). Main outcome measures The main outcome measures were the percentage of participants retested at 1–4 months after chlamydia diagnosis and the percentage in each arm with repeat positive tests, by risk group and overall, analyzed by intention to treat. Data were collected from 2011 to 2013 and analyzed in 2014. Results The percentage retested within 1–4 months of chlamydia diagnosis was significantly higher in home versus clinic arm participants among women (64% [66/103] vs 39% [38/97], p p =0.002); men who have sex with men (62% [61/98] vs 44% [45/102], p =0.010); and overall (61% [184/302] vs 39% [117/298], p p =0.021) and overall (10% [31/302] vs 4% [12/298], p =0.006). Conclusions The addition of a postal home collection kit to routine SMS reminders resulted in substantial improvements in chlamydia retesting rates in all three risk groups and detection of more repeat positive tests, compared with SMS alone. Extending the intervention to other primary care settings with low retesting rates should be considered.

Frequent testing of individuals at high risk of HIV is central to current prevention strategies. We aimed to determine if HIV self-testing would increase frequency of testing in high-risk gay and bisexual men, with a particular focus on men who delayed testing or had never been tested before.In this randomised trial, HIV-negative high-risk gay and bisexual men who reported condomless anal intercourse or more than five male sexual partners in the past 3 months were recruited at three clinical and two community-based sites in Australia. Enrolled participants were randomly assigned (1:1) to the intervention (free HIV self-testing plus facility-based testing) or standard care (facility-based testing only). Participants completed a brief online questionnaire every 3 months, which collected the number of self-tests used and the number and location of facility-based tests, and HIV testing was subsequently sourced from clinical records. The primary outcome of number of HIV tests over 12 months was assessed overall and in two strata: recent (last test ≤2 years ago) and non-recent (2 years ago or never tested) testers. A statistician who was masked to group allocation analysed the data; analyses included all participants who completed at least one follow-up questionnaire. After the 12 month follow-up, men in the standard care group were offered free self-testing kits for a year. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12613001236785.Between Dec 1, 2013, and Feb 5, 2015, 182 men were randomly assigned to self-testing, and 180 to standard care. The analysis population included 178 (98%) men in the self-testing group (174 person-years) and 165 (92%) in the standard care group (162 person-years). Overall, men in the self-testing group had 701 HIV tests (410 self-tests; mean 4·0 tests per year), and men in the standard care group had 313 HIV tests (mean 1·9 tests per year); rate ratio (RR) 2·08 (95% CI 1·82-2·38; p0·0001). Among recent testers, men in the self-testing group had 627 tests (356 self-tests; mean 4·2 per year), and men in the standard care group had 297 tests (mean 2·1 per year); RR 1·99 (1·73-2·29; p0·0001). Among non-recent testers, men in the self-testing group had 74 tests (54 self-tests; mean 2·8 per year), and men in the standard care group had 16 tests (mean 0·7 per year); RR 3·95 (2·30-6·78; p0·0001). The mean number of facility-based HIV tests per year was similar in the self-testing and standard care groups (mean 1·7 vs 1·9 per year, respectively; RR 0·86, 0·74-1·01; p=0·074). No serious adverse events were reported during follow-up.HIV self-testing resulted in a two times increase in frequency of testing in gay and bisexual men at high risk of infection, and a nearly four times increase in non-recent testers, compared with standard care, without reducing the frequency of facility-based HIV testing. HIV self-testing should be made more widely available to help increase testing and earlier diagnosis.The National Health and Medical Research Council, Australia.

Background Chlamydia retesting three months after treatment is recommended to detect reinfections, but retesting rates are typically low. The REACT (retest after Chlamydia trachomatis) randomised trial demonstrated that home-based retesting using postal home-collection kits and SMS reminders, resulted in substantial improvements in retesting rates in women, heterosexual men and men who have sex with men (MSM), with detection of more repeat positive tests compared with SMS reminder alone. In the context of this trial, the acceptability of the home-based strategy was evaluated and the costs of the two strategies were compared. Methods REACT participants (200 women, 200 heterosexual men, 200 MSM) were asked to complete an online survey that included home-testing acceptability and preferred methods of retesting. The demographics, sexual behaviour and acceptability of home collection were compared between those preferring home-testing versus clinic-based retesting or no preference, using a chi-square test. The costs to the health system of the clinic-based and home retesting strategies and the cost per infection for each were also compared. Results Overall 445/600 (74 %) participants completed the survey; 236/445 from the home-testing arm, and 141 of these (60 %) retested at home. The majority of home arm retesters were comfortable having the kit posted to their home (86 %); found it easy to follow the instructions and collect the specimens (96 %); were confident they had collected the specimens correctly (90 %); and reported no problems (70 %). Most (65 %) preferred home retesting, 21 % had no preference and 14 % preferred clinic retesting. Comparing those with a preference for home testing to those who didn’t, there were significant differences in being comfortable having a kit sent to their home (p = 0.045); not having been diagnosed with chlamydia previously (p = 0.030); and living with friends (p = 0.034). The overall cost for the home retest pathway was $154 (AUD), compared to $169 for the clinic-based retesting pathway and the cost per repeat infection detected was $1409 vs $3133. Conclusions Among individuals initially diagnosed with chlamydia in a sexual health clinic setting, home-based retesting was shown to be highly acceptable, preferred by most participants, and cost-efficient. However some clients preferred clinic-based testing, often due to confidentiality concerns in their home environment. Both options should be provided to maximise retesting rates. Trial registration The trial was registered with the Australia New Zealand Clinical Trials Registry on September 9, 2011: ACTRN12611000968976. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-2727-4) contains supplementary material, which is available to authorized users.

Gay and bisexual men (GBM) are a major risk group for HIV acquisition, yet the majority of higher-risk GBM test for HIV less often than recommended (3–6 monthly). HIV self-testing has the potential to increase testing frequency and improve awareness of personal HIV status. HIV self-tests have been approved in some countries, however there are concerns whether self-testing would increase HIV testing frequency enough to compensate for the reduced sensitivity of self-tests in early infection. We describe here a randomised controlled trial to assess the effectiveness of self-testing in increasing HIV testing frequency among higher-risk GBM, and its acceptability. Participants are higher-risk HIV negative GBM (>5 partners or condomless anal intercourse in previous 3 months; n = 350), including 50 GBM who tested for HIV over two years ago or never tested before (‘infrequent-testers’). Participants are recruited from sexual health clinics and community-based organisations, and randomised 1:1 to either self-testing or standard-care (routine clinic-based testing) arms. The trial employs a wait-list control design: participants in the standard-care arm switch to self-testing arm in the second year, and gain access to self-test kits. Participants in the self-testing arm receive four oral-fluid self-test kits at enrolment, with additional kits provided on request. Demographics, sexual behaviour and HIV testing preferences are collected at baseline, and the frequency and pattern of HIV and sexually transmissible infection (STI) testing is collected via online 3-monthly questionnaires. The acceptability of self-testing is assessed at 12 months via an online questionnaire and in-depth interviews. A 24-h telephone support is provided, with expedited follow-up of those with reactive self-test results. The primary outcome is HIV testing frequency (mean number of HIV tests per person) over 12 months, and the secondary outcomes are: mean number of STI tests (chlamydia, gonorrhoea, syphilis) per person; reasons for HIV testing; and acceptability of HIV self-testing. This is the first trial to evaluate the use of self-testing among GBM in Australia, and the first internationally among infrequent testers. The study will provide evidence on whether self-testing increases HIV testing frequency, and its acceptability among GBM. The findings will improve our understanding of self-testing patterns, and whether GBM supplement or replace their existing testing routine. Australian and New Zealand Clinical Trial Registration number: ACTRN12613001236785 , registered on November 12, 2013.

There are high rates of Trichomonas vaginalis in remote areas of Central Australia. Conventional tests for T. vaginalis have low sensitivity in this setting. Aims of the study were to estimate the prevalence of T. vaginalis, to assess the presence of clinical signs and symptoms, to compare a T. vaginalis polymerase chain reaction (PCR) test with conventional methods of diagnosis, and to compare the PCR from different samples, including self-collected swabs (SCS). Of 205 women recruited, the prevalence of T. vaginalis was 24%. The prevalence of T. vaginalis was higher in women under 25 years (33%), compared with those who were 25–34 years (26%) and those over 35 years (15%, P < 0.05). The sensitivity of T. vaginalis PCR detection from SCS (94%) was not statistically different from a practitioner-collected HVS (96%), but was superior to urine PCR (74%) and conventional methods. After multivariate analysis, those women with high pH were almost three times more likely to be positive for T. vaginalis (odds ratio = 2.71 with 95% confidence interval 1.06–6.93, P = 0.037). Superior assays such as PCR should be a diagnostic option to adequately screen and treat women with T. vaginalis, in order to reduce complications, including the increased risk of HIV transmission.

Background Regular testing of individuals at higher-risk of HIV is central to current prevention strategies. The aim of the present study was to examine the extent to which confidence in one’s perceived ability to undertake various aspects of HIV testing and self-testing (self-efficacy) affected HIV testing outcomes. We assessed factors, including self-efficacy, associated with HIV testing frequency and the likelihood to self-test among gay and bisexual men (GBM). Methods: Participants were HIV-negative GBM at an increased risk of HIV (more than five partners or condomless anal intercourse in the previous 3 months) enrolled in a randomised controlled trial of HIV self-testing. The baseline questionnaire captured data regarding sociodemographic characteristics, HIV and/or sexually transmissible infection testing history, sexual behaviour, beliefs and attitudes towards HIV and eight items capturing confidence in HIV testing ability that were combined as a single broad measure of HIV testing self-efficacy (α = 0.81). Factors associated with three or more HIV tests in the past year and the likelihood of self-testing in the future were determined using logistic regression. Results: Of 354 GBM, 34% reported three or more HIV tests in the past year, and 64% reported being ‘very likely’ to self-test. Factors independently associated with three or more HIV tests in the past year were: higher self-efficacy (adjusted odds ratio (aOR) 1.08 per unit increase; 95% confidence interval (CI) 1.02–1.14; P = 0.004); >10 male partners in the past 6 months (aOR 1.79; 95% CI 1.05–3.04; P = 0.031) and higher optimism regarding the effects of HIV treatments on HIV transmission (aOR 1.14; 95% CI 1.00–1.29; P = 0.044). Only higher self-efficacy was independently associated with reporting a greater likelihood to self-test in the future (aOR 1.10; 95% CI 1.05–1.15; P < 0.001). Conclusions: Improving self-efficacy by enhancing GBM’s knowledge and experience may lead to higher testing frequency. The self-efficacy measure used in the present study could be useful in identifying GBM likely to face difficulties with HIV testing and self-testing.

Introduction Regular testing of individuals at high risk of HIV is central to current prevention strategies, and crucial to decrease the time-to-diagnosis. Little research has been conducted on ‘self-efficacy’: the perceived ability to undertake HIV testing among gay and bisexual men (GBM). We examined self-efficacy in relation to HIV testing frequency and likelihood to self-test among GBM. Methods Participants were HIV-negative GBM at increased risk of HIV (>5 partners or any condomless anal intercourse in previous 3 months) in a randomised controlled trial of HIV self-testing (FORTH). Participants completed a baseline survey at enrolment. We constructed a HIV Testing Self-Efficacy (HTSE) scale measuring confidence in one’s perceived ability to undertake HIV testing comprising 8 items (‘not at all confident’ = 0 to ‘completely confident’ = 4; Cronbach’s α = 0.81). Total HTSE score consisted of the sum of scores for all items. We determined the factors associated with HIV testing frequency in the past 12 months and perceived likelihood to self-test in the future using logistic regression. Results A total of 355 GBM were included. Median age was 33 years (inter-quartile range [IQR] = 26–41), and 63% were Australian-born. Overall, 95% reported having previously tested for HIV, and 65% reported being ‘very likely’ to self-test for HIV. The median HTSE score was 26 (IQR = 23–29, range = 8–32). In multivariate analysis, factors independently associated with ≥3 HIV tests in past 12 months were: HTSE score (adjusted odds ratio [AOR] = 1.07 for one unit increase, 95% CI = 1.02–1.13, p = 0.011); and >10 partners in past 6 months (AOR = 1.85,95% CI = 1.10–3.12, p = 0.020). Only HTSE score was associated with being ‘very likely’ to self-test (OR = 1.08, 95% CI = 1.03–1.13, p = 0.001). Conclusion HIV testing self-efficacy is independently associated with testing frequency and likelihood to self-test. Improving GBM’s confidence in HIV testing, by improving their knowledge and experience may lead to higher testing frequency. Future longitudinal analysis will provide information about the causal pathways between HTSE, testing frequency and actual self-testing measured in the trial. Disclosure of interest statement The research is funded through a NHMRC Program grant from the NHMRC and self-test kits were purchased from OraSure Technologies Inc. (Bethlehem, PA, USA). The Kirby Institute and the Centre for Social Research in Health receive funding from the Australian Government Department of Health.

Background In Australia, despite dramatic increases in chlamydia notifications and recommendations that young people be tested annually, testing rates in general practice remain low. ACCEPt is a randomised controlled trial to evaluate the impact of chlamydia testing on prevalence. General practitioners (GPs) in the intervention arm received regular feedback on testing performance, visual reminders and incentive payments to facilitate increased testing. To assess the acceptability of the intervention, participating GPs were interviewed at baseline and midpoint to investigate their chlamydia management practices and their opinions about the intervention. Methods Semi-structured interviews were conducted with purposively sampled GPs prior to randomization (baseline) and after one year in the intervention (midpoint) until saturation was reached. Data were analysed both thematically and using Normalisation Process Theory (NPT), a framework that explains how complex interventions can be successfully implemented, embedded and integrated in institutional settings. Emerging themes from each timepoint were compared and interpreted within the NPT framework. Results A total of 44 GPs at baseline and 24 GPs at midpoint were interviewed. The ACCEPt intervention increased GPs’ comfort and ease in offering a test, and were associated with a shift in attitudes from symptom-based testing to age-based testing. Many GPs highlighted that feedback, a key aspect to embedding the intervention, was a major driver of increased testing. The intervention was gradually implemented over time through increasing awareness and engagement with education and exposure to the project. Logistical issues, such as remembering to offer a test, were overcome with practical facilitators like computer alerts. However, integration was limited as not all GPs utilised the intervention components or other clinic staff to increase testing because of restrictions in clinic structure. Conclusion GPs reported that the ACCEPt intervention and its implementation within the NPT framework have been effective at facilitating chlamydia testing in general practice. Disclosure of interest statement ACCEPt was commissioned and funded by the Australian Government Department of Health and Ageing. Additional funding has been received from the National Health and Medical Research Council, the Victorian Department of Health and NSW Health.

Background Chlamydia retesting at three months after treatment is recommended to detect reinfections, but retesting rates are low. We assessed the impact of combining home-collection with SMS reminders on retesting rates in three risk groups. Methods A randomised controlled trial was undertaken, involving 600 participants diagnosed with chlamydia: 200 men who have sex with men (MSM), 200 women and 200 heterosexual men. Participants were recruited from two Australian sexual health clinics and randomised to the home group (3-month SMS reminder and home-collection) or the clinic group (SMS reminder). The mailed home-collection kit included a self-collected vaginal swab (women), UriSWAB (Copan) for urine collection (heterosexual men), and UriSWAB plus rectal swab (MSM). The primary outcome was the proportion retested at 1–4 months after chlamydia diagnosis, and the secondary outcome was the proportion with repeat positive results at the 1–4 month retest. Any testing outside the study sites was collected and included in the outcomes. An intention to treat analysis was conducted. Results Overall 61% (183/300) of home group participants retested within 1–4 months of chlamydia diagnosis compared with 39% (118/300) in the clinic group (p Conclusion SMS reminders combined with home-based collection was a very effective strategy to increase chlamydia retesting in all three risk groups, and also detected additional repeat infections in MSM. The acceptability to patients and health care provider costs are currently being evaluated.

Background Repeat infection with Chlamydia trachomatis is common and increases the risk of sequelae in women and HIV seroconversion in men who have sex with men (MSM). Despite guidelines recommending chlamydia retesting three months after treatment, retesting rates are low. We are conducting the first randomised controlled trial to assess the effectiveness of home collection combined with short message service (SMS) reminders on chlamydia retesting and reinfection rates in three risk groups. Methods/Design The REACT (retest after Chlamydia trachomatis) trial involves 600 patients diagnosed with chlamydia: 200 MSM, 200 women and 200 heterosexual men recruited from two Australian sexual health clinics where SMS reminders for retesting are routine practice. Participants will be randomised to the home group (3-month SMS reminder and home-collection) or the clinic group (3-month SMS reminder to return to the clinic). Participants in the home group will be given the choice of attending the clinic if they prefer. The mailed home-collection kit includes a self-collected vaginal swab (women), UriSWAB (Copan) for urine collection (heterosexual men), and UriSWAB plus rectal swab (MSM). The primary outcome is the retest rate at 1-4 months after a chlamydia diagnosis, and the secondary outcomes are: the repeat positive test rate; the reinfection rate; the acceptability of home testing with SMS reminders; and the cost effectiveness of home testing. Sexual behaviour data collected via an online survey at 4-5 months, and genotyping of repeat infections, will be used to discriminate reinfections from treatment failures. The trial will be conducted over two years. An intention to treat analysis will be conducted. Discussion This study will provide evidence about the effectiveness of home-collection combined with SMS reminders on chlamydia retesting, repeat infection and reinfection rates in three risk groups. The trial will determine client acceptability and cost effectiveness of this strategy. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12611000968976.