Evaluation of Enhanced Syphilis Screening Among HIV-positive Men Who Have Sex With Men
This study aims to enhance syphilis testing among HIV-positive men who have sex with men (MSM), so that more men will undergo testing, they will test more often, and more cases will be treated early. The intervention will combine syphilis tests with the standard HIV blood tests that are routinely done every 3-6 months for persons in care at hospital-based HIV clinics in Toronto and Ottawa, Canada.
|Study Design:||Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: Open Label
Primary Purpose: Screening
|Official Title:||Enhanced Syphilis Screening Among HIV-positive Men Who Have Sex With Men: Evaluation of a Clinic-based Intervention|
- Change in rate of detection of new, previously untreated syphilis cases [ Time Frame: At 30 months ] [ Designated as safety issue: No ]We will use a cluster-randomized controlled trial (CRCT) using a stepped wedge design that will gradually introduce the intervention across four clinics. Each clinic will be randomized to one of the four roll-out periods, and will have at minimum one 6-month control period and one 6-month intervention period. The main hypothesis to be tested is H0: θ=0 versus Ha: θ= θa where θ represents the increase in the case detection rate due to the intervention and θa represents a 75% increase over the baseline rate.
- Change in screening coverage [ Time Frame: At 30 months ] [ Designated as safety issue: No ]Proportion tested for syphilis at least once per year
- Change in screening frequency [ Time Frame: At 30 months ] [ Designated as safety issue: No ]Number of times tested for syphilis, per year.
- Direct and indirect costing of each additional screen-detected syphilis diagnosis [ Time Frame: Month 30 ] [ Designated as safety issue: No ]Costs will include inpatient services (initial screening and follow-up management costs), drug costs, syphilis test kits and technician time.
|Study Start Date:||July 2014|
|Estimated Study Completion Date:||December 2016|
|Estimated Primary Completion Date:||December 2016 (Final data collection date for primary outcome measure)|
Experimental: Syphilis testing with routine HIV bloodwork
The intervention condition will be implemented as standing orders for syphilis serology whenever patients undergo their standard battery of follow-up bloodwork, i.e., when there is an order for HIV viral load or CD4 cell count.
Other: Syphilis testing with routine HIV bloodwork
The intervention condition will be implemented as standing orders for syphilis serology whenever patients undergo their standard battery of follow-up bloodwork, i.e., when there is an order for HIV viral load or CD4 cell count. It is standard practice for HIV patients to undergo such tests every 3-6 months. We anticipate that the change in practice will be straightforward, involving minimal training of clinic staff. Team members who are physicians at these clinics will guide the specific approach that will be appropriate and sustainable for their setting. Options are quite simple. They include pre-printing a checkmark for 'syphilis serology' onto existing pre-printed requisitions for routine bloodwork; addition of the serology request form to the routine blood work package; or programming 'syphilis serology' into existing computerized routine order sets.
No Intervention: Current care practice
The control condition will remain the current care practice, which is generally opportunistic screening or diagnostic testing for those presenting with signs/symptoms or who report sexual risk behaviour.
A clinic-based intervention to incorporate syphilis testing with routine HIV bloodwork among HIV-positive men who have sex with men (MSM) attending 4 hospital-based HIV clinics in Toronto and Ottawa will be conducted. The objectives are to determine to what degree the intervention: (1) increases the proportion of men who undergo syphilis testing at least annually (screening coverage); (2) shortens the interval between tests (screening frequency); (3) reaches men at highest risk; and, ultimately, (4) results in more detected cases of untreated, and especially infectious, syphilis and the incremental cost to the health-care system for each additional diagnosis. The main hypotheses are that the intervention will increase screening coverage to a minimum of 85% of men undergoing syphilis testing annually, increase screening frequency to a median of 3 tests per person per year, and increase the case detection rate by 75% or more.
The design of this study is a cluster-randomized controlled trial with stepped wedge design that will gradually introduce the intervention across clinics. This pragmatic approach incorporates a concurrent comparison group, allows for assessment of time trends, will be well-powered, and will generate more generalizable results due to its inclusion of multiple clinics. The intervention will be operationalized as standing orders for syphilis serology when there is an order for HIV viral load and/or CD4 cell count. Data sources include (1) syphilis tests submitted to the Public Health Ontario Laboratory; (2) a standardized clinical worksheet and medical chart review to validate diagnoses for screen test positives; and (3) data collected from a subset of patients via their participation in the ongoing Ontario HIV Treatment Network (OHTN) Cohort Study. The latter follows adults in HIV care and collects data using chart reviews and annual face-to-face interviews including measures of sexual behaviour.
|Contact: Ann N Burchell, PhD||416-642-6486 ext email@example.com|
|Ottawa General Hospital||Not yet recruiting|
|Ottawa, Ontario, Canada, K1H 8L6|
|Contact: Paul A MacPherson, MD firstname.lastname@example.org|
|Principal Investigator: Paul A Macpherson, MD|
|Toronto General Hospital||Not yet recruiting|
|Toronto, Ontario, Canada, M5G 2C4|
|Contact: Sharon L Walmsley, MD email@example.com|
|Principal Investigator: Sharon L Walmsley, MD|
|Sunnybrook Health Sciences Centre||Not yet recruiting|
|Toronto, Ontario, Canada, M4N 3M5|
|Contact: Anita Rachlis, MD firstname.lastname@example.org|
|Principal Investigator: Anita Rachlis, MD|
|St. Michael's Hospital||Not yet recruiting|
|Toronto, Ontario, Canada, M5B 1W8|
|Contact: Kevin Gough, MD email@example.com|
|Principal Investigator: Kevin Gough, MD|
|Principal Investigator:||Ann N Burchell, PhD||Ontario HIV Treatment Network|