update on the strive trial - kirby institute...6.3 year 1 7.9 year 1 4.5 year 1 1.6 year 2 7.2 year...
TRANSCRIPT
Update on the STRIVE trial
John KaldorKirby Institute, UNSW
Kirby Institute Symposium27 June 2013
Background• High rates of curable STIs in remote communities
• Major consequences– Unpleasant symptoms– Personal and social impact– Reproductive tract damage– HIV risk
• We have accurate tests and effective treatments
• Population screening and treatment as a key control strategy since the mid 1990s
Chlamydia notifications, Australia 2011
0
500
1000
1500
2000
2500
3000
3500
4000
Major cities Inner regional Outer regional Remote Very remote
Rate per 100
000
Area of residence
Aboriginal and Torres Strait Islander Non‐Indigenous
Source: State/Territory health authorities1 Jurisdictions (NT, SA, TAS, VIC and WA) in which Aboriginal and Torres Strait Islander status was reported for more than 50% of diagnoses
Gonorrhoea notifications, Australia 2011
0
500
1000
1500
2000
2500
3000
3500
4000
Major cities Inner regional Outer regional Remote Very remote
Rate per 100
000
Area of residenceAboriginal and Torres Strait Islander Non‐Indigenous
Source: State/Territory health authorities1 Jurisdictions (NT, QLD, SA, TAS, VIC and WA) in which Aboriginal and Torres Strait Islander status was reported for more than 50% of diagnoses
Infectious syphilis notifications, Australia 2011
0
20
40
60
80
100
120
140
Major cities Inner regional Outer regional Remote Very remote
Rate per 100
000
Area of residenceAboriginal and Torres Strait Islander Non‐Indigenous
Source: State/Territory health authorities1 Jurisdictions (NSW, NT, QLD, SA, TAS, VIC, ACT and WA) in which Aboriginal and Torres Strait Islander status was reported for more than 50% of diagnoses
Hepatitis C notifications, Australia 2011
0
50
100
150
200
250
300
350
400
450
Major cities Inner regional Outer regional Remote Very remote
Rate per 100
000
Area of residenceAboriginal and Torres Strait Islander Non‐Indigenous
Source: State/Territory health authorities1 Jurisdictions (NT, SA, TAS and WA) in which Aboriginal and Torres Strait Islander status was reported for more than 50% of diagnoses.
HIV diagnoses in Australia
0
1
2
3
4
5
6
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Age
sta
ndar
dise
d ra
te
per
100
000
Year
Aboriginal and Torres Strait Islander Non-Indigenous1 Cases and populations from high prevalence countries were excluded from the non‐Indigenous rate.
Successes in STI control for remote communities
• Substantial variation in implementation• Some major successes• No large scale systematic evaluation• Need for a deeper understanding of STI transmission and how to achieve control in remote communities
Tiwi3 clinicsPop 2126
NT DoH28 clinicsPop 8537
Reference: Guy et al, Sex Health, 2012;9:205‐212
Nganampa6 clinicsPop 2734
Ngaanyatjarra12 clinicsPop 1800
STI testing in APY lands and Tiwi
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
% of p
opulation tested
for C
T an
d NG
Average nu
mbe
r of tests per week
Year
Opportunistic STI testing, APY lands, SA Community and opportunistic testing, Tiwi Islands, NT
Reference: Guy et al, Sex Health, 2012;9:205‐212
Prevalence of STIs in APY lands, 14‐40 y.o.
Reference: Guy et al, Sex Health, 2012;9:205‐212
Prevalence of STIs in NHS areas
Reference: Guy et al, Sex Health, 2012;9:205‐212
Prevalence of STIs in Tiwi
Reference: Guy et al, Sex Health, 2012;9:205‐212
Prevalence of STIs in NT communities
Reference: Guy et al, Sex Health, 2012;9:205‐212
The STRIVE trial• NHMRC funded project grant 2009‐2014
• Multi‐jurisdiction, stepped wedge, cluster randomised trial, involving government and community controlled services
• Sexual health quality improvement program
• STRIVE aims to determine whether the program
1. Can achieve best practice targets in sexual health clinical service delivery
2. Can reduce overall prevalence of STIs in communities?
Reference: Guy et al, Sex Health, 2012;9:205‐212
STRIVE sites69 communities24 clusters
CENTRAL AUSTRALIA
TOP END
CAPE YORK
KIMBERLEY
STRIVE primary outcomes
Prevalence of chlamydia, gonorrhoea and
trichomonas in 16‐34 year olds
• Testing coverage• Time to treatment• 3 month testing for re‐infection• Contact tracing
STRIVE management structure
STRIVE Indicators and Targets
SCREEN
Resident population aged 16‐34 years
TREAT QUICKLY
Symptomatic infection – treat immediatelyAsymptomatic infection – treat within 7 days of receiving a pathology result
TEST FOR RE‐INFECTION
For people with a positive result, test at 3 months after treatment
CONTACT REFERRAL
Test and treat named contacts within 14 days
STRIVE quality improvement cycle
Incentive payments
Health promotion
STRIVE data collection
Routine clinical and laboratory records Redesign of clinic information systems Regular transfer and analysis of data sets A work in progress
New clinical STI templates
The STRIVE field coordinators
• Keep sexual health on the agenda• Work with services to do systems assessments• Assist with development of action plans• Provide regular quantitative feedback on progress
STRIVE systems assessment tool:Baseline
0.4
7.0
6.3
7.9
4.5
1.6
0.01.02.03.04.05.06.07.08.09.0
10.011.0
Health Hardware
Clinical Services
Information Systems
Health Promotion
Organisational Commitment
Surveillance & Evaluation
Year 1
STRIVE systems assessment after one year
Year 10.4
Year 17.0
Year 16.3
Year 17.9
Year 14.5
Year 11.6
Year 27.2
Year 27.1
Year 28.5
Year 26.0
Year 25.2
Year 26.0
0.01.02.03.04.05.06.07.08.09.010.011.0
Health Hardware
Clinical Services
Information Systems
Health Promotion
Organisational Commitment
Surveillance & Evaluation
Red numbers are clinic score for 2012
Year 1Year 2
STRIVE cluster randomisation
0
5
10
15
20
25
2011 2012 2013
Num
ber o
f clusters
Start of quality improvement program
SHQIPControl
STRIVE cluster randomisation
0
5
10
15
20
25
2011 2012 2013
Num
ber o
f clusters
Start of quality improvement program
SHQIPControl
STRIVE cluster randomisation
0
5
10
15
20
25
2011 2012 2013
Num
ber o
f clusters
Start of quality improvement program
SHQIPControl
STRIVE timeline
2008 2009 2010 2011 2012 2013 2014 2015
Sexual Health Quality
Improvement Program(SHQIP) –Year 1 sites
SHQIP– Year 2 sites
SHQIP– Year 3 sites
Consultation with health services and stakeholders
Ethical approval granted
Prevalenceassessment
Randomisation
Prevalenceassessment
Prevalenceassessment
Analysis and write up
Analysis and write up
STRIVE baseline testing for trichomonas
920 760 934
2617
2101 2106
0
500
1000
1500
2000
2500
3000
3500
4000
16‐24 25‐34 35+
Num
ber o
f tests
Age groupMales Females
STRIVE baseline testing for chlamydia and gonorrhoea
15851340
1697
3533
2891 2996
0
500
1000
1500
2000
2500
3000
3500
4000
16‐24 25‐34 35+
Num
ber o
f tests
Age groupmales females
STRIVE baseline chlamydiaprevalence (n=2536)
0%
5%
10%
15%
20%
25%
30%
16‐19 20‐24 25‐29 30‐34
Chlamydia prevalence (%
)
Age group (years)
MalesFemales
STRIVE baseline gonorrhoea prevalence (n=2536)
0%
5%
10%
15%
20%
25%
30%
16‐19 20‐24 25‐29 30‐34
Gon
orrhoe
a prevalen
ce (%
)
Age group (years)
MalesFemales
STRIVE baseline trichomonasprevalence (n=1828)
0%
5%
10%
15%
20%
25%
30%
16‐19 20‐24 25‐29 30‐34
T. vag
inalisprevalen
ce (%
)
Age group (years)
MalesFemales
STRIVE baseline chlamydia incidence
18%
9%
3%
23%
10%
4%
0%
5%
10%
15%
20%
25%
30%
16‐24 25‐34 35+
Prop
ortio
n po
sitiv
e
Age group (years)
MalesFemales
STRIVE baseline gonorrhoea incidence
19%
10%
3%
18%
7%
2%
0%
5%
10%
15%
20%
25%
30%
16‐24 25‐34 35+
Prop
ortio
n po
sitiv
e
Age group (years)
MalesFemales
STRIVE baseline trichomonas incidence
6% 6%8%
29%
22%20%
0%
5%
10%
15%
20%
25%
30%
16‐24 25‐34 35+
Prop
ortio
n po
sitiv
e
Age group (years)
MalesFemales
What next for STRIVE?• Finish the trial (2014)• Understand what we have learned about
– Increasing uptake of best practice– Sustaining best practice– Barriers and incentives to best practice– Extent to which control has been achieved
• Continue to learn, innovate and translate– Improve access to testing and treatment– Strengthen capacity in remote communities– Interaction with other health priority areas
Acknowledgements
• James Ward• Rebecca Guy• Alice Rumbold• Handan Wand• Matthew Law• Lisa Maher• Basil Donovan• Kit Fairley• Nathan Ryder• Liz Moore• Jacki Mein
• Skye McGregor• Linda Garton• Amalie Dyda• Bronwyn Silver• Deb Taylor Thomson• Belinda Hengel• Janet Knox
• Participating services• Diagnostic laboratories• Health departments