1. Dual Diagnostic Technologies UZ-UCSF COLLABORATIVE RESEARCH PROGRAMME ANNUAL RESEARCH DAY 17 APRIL 2015 Dr Evaristo Marowa Dermato-Venereologist

2. Approach to STI Case Management STIs are common and serious especially to women and neonates Effective case management is a cornerstone of control Given at “point of first contact” it: – Decreases spread and prevents complications – Targets STI/HIV counselling and education to a receptive audience

3. STI – Syndromic Case Management ADVANTAGES Identifies and treats by signs & symptoms Syndromes easily recognised clinically Small number of clinical syndromes Treatment given for majority of organisms Simple and cost-effective Valid, feasible, immediate treatment Risk assessment increases performance

4. STI – Syndromic Case Management DISADVANTAGES Tendency to overtreat – justifiable in high prevalence settings (>10%) Decreased specificity Overuse of expensive drugs Management of cervical infections problematic Vaginal discharge algorithm performs poorly in low prevalence GC and Chlamydia settings e.g., ANC, FP populations

5. STI – Syndromic Case Management REQUIREMENTS Adequate medical history Good sexual history Complete STI clinical examination Management guidelines Good supply of effective medicines

6. 2 nd Generation Syndromic Diagnosis Approach Action Condom use Other action Partner notification Symptom + sign Particularly vaginal discharge or GUD Decision Incorporate rapid diagnostic test Risk assessment

7. Decision flowchart for introducing a new diagnostic test Yes No Good Is testing currently available or possible at the facility? Access, coverage and quality? Maintain current system Ensure continued/improved quality control programme Poor Can current system be fixed? Yes No Introduce new diagnostic test(s)

8. Current Rapid Tests for Syphilis (Equivalent to TPHA) CT S CT S CT S Negative Positive Invalid Procedure: 1.Use dropper provided, dispense 1 drop of serum/whole blood to sample well S 2. Add 2 drops of diluent buffer to sample well S 3. Read results at 15 minutes

9. Bioline Treponemal Point-of-care (POC) Test

10. 1. Add 5  l of serum/blood to the sample+buffer well. 2. Add 2 drops of buffer to the sample+buffer well. 3. Add five drops of buffer to the buffer well when the colored lines disappear. 4. Read the results at 15 minutes Negative result: one linePositive result: two linesor 12345678 Chembio Syphilis POC Test Procedure Chembio Syphilis POC Test Procedure

11. Ideal, conventional diagnostic algorithm for the diagnosis of active syphilis – RPR+TPHA Confirmed syphilis TREAT No treatment necessary Serum RPR +ve -ve Treponemal test +ve -ve Figure 12

12. Patient Name or Number Cardiolipin Antigen Spot (RPR equivalent) Treponemal Antigen Spot (TPHA equivalent) Control Spot Span ‘Signal Spirolipin’ Flow-through Syphilis Dual Test Platform

13. Addition of wash buffer Addition of serum Addition of wash buffer Addition of conjugate Addition of wash buffer Step 1 Step 2Step 3 Step 4 Step 5

14. Rapid Simultaneous Detection of Reagin and Treponemal Antibodies Using the ‘Signal Spirolipin’ Flow-through Test NON –REACTIVE TESTS ONLY THE NON-SPECIFIC CARDIOLIPIN TEST REACTIVE ONLY THE TREPONEMAL TEST REACTIVE CONFIRMED REACTIVE TEST

15. Field testing by CDC-USA in Madagascar (Courtesy Prof Ron Ballard)

16. Chembio Dual Cardiolipin / Treponemal Test

17. Whole Blood sample Dual (combined) rapid syphilis diagnostic test Tp –ve, NTp -veTp –ve, NTp +veTp +ve, NTp -veTp +ve, NTp +ve Active infection. Initiate treatment Past/early syphilis Retest in 4-6 weeks to confirm Biological false +ve, no treatment Uninfected, no treatment Tp = Treponemal result Ntp = Non=treponemal result Syphilis testing and treatment algorithm with dual diagnostic test

18. The Future: Dual testing for HIV and syphilis

19. The future multiplex technology for diagnosis of urethral discharge Amplified nucleic acid based testing - for N. gonorrhoeae - for C. trachomatis - for M. genitalium - ? for U. urealyticum - for T. vaginalis

20. The future multiplex technology for diagnosis of vaginal discharge syndrome Amplified nucleic acid based testing - for T. vaginalis - for N. gonorrhoeae - for C. trachomatis - for M. genitalium

21. Criteria for choice of tests for purposes of procuremet Cost Test Performance Stability Need for additional supplies, e.g. micropipette Format: dipstick vs cassette Training required Ease of interpretation of results Regulatory approval in country accuracy reproducibility

22. Quality Assurance Quality control of tests (QC) – Rapid tests have no internal QC – Need to monitor transport and storage conditions (temperature and humidity) - Temperature spiking in transit - Storage at central stores - Storage at health-care facilities at all levels Quality of testing – EQA (proficiency) – Quality system throughout health-care infrastructure – National reference labs, regional, district, health centre

23. The Future Goal The development of integrated diagnostic platforms that are rapid, easy to use, sensitive and specific to detect multiple targets for diagnosis of infectious diseases oral rapid tests to screen for HIV/syphilis, other viral STIs Determination of antimicrobial resistance For monitoring treatment and prevention For use in peripheral point-of-care settings Access ensured in low resource settings

24. Tatenda Thank you Merci