Cheryl Guttman Krader, BS, Pharm

	The 2015 STD Treatment Guidelines released by the Centers for Disease Control and Prevention (CDC) in June 2015, include several major updates to the section on trichomoniasis.

	The new guidelines were developed based on a thorough review of current scientific evidence, said Elissa Meites, MD, MPH, a medical epidemiologist at the CDC, who led development of the section. 

	She added, however, that an examination of available literature supports the notion that trichomoniasis is a “neglected” infection about which many important questions remain unanswered. 

	Dr Meites is lead author of the published paper that reviews scientific evidence used for the development of the 2015 STD Treatment Guidelines section on trichomoniasis.

 She also wrote and coauthored other articles reviewing and discussing trichomoniasis as a neglected infection.

	As noted in the latter paper, research and control efforts for 

 infection traditionally have lagged far behind efforts for other sexually transmitted infections (STIs), even though 

 infection is the most prevalent non-viral STI in the United States and more common than chlamydia, gonorrhea, and syphilis infections combined.

	The authors concluded, “Increased emphasis on detection and treatment of infections is needed to move trichomoniasis out of the neglected category and to provide better care for those most impacted by this parasitic disease.”

	As noted in the published paper, poor understanding of its public health impact is one important factor in the low level of attention given to 

	Whether trichomoniasis should be a reportable condition was the subject of a recent editorial from the CDC.

 As stated in this paper, 7 criteria of public health importance determine whether a condition warrants surveillance-indices of frequency, disparities or inequities, communicability, severity, costs, preventability of complications, and public interest. 

 infection, however, meets only the first three.

	“Further studies are needed to develop the evidence base for 

 infection to be considered an STI of higher public health priority,” Dr Meites and colleagues concluded. Specific issues  for current and future research include examination of the epidemiology of trichomoniasis among men and women; the true public health burden of symptomatic and asymptomatic 

 infections; and whether current treatments will be adequate to reduce health disparities and costs associated with trichomoniasis. 

	“Trichomoniasis is so common, but people forget about it because it doesn’t often cause problems - and when it does, it is treatable. Also, for a long time, this infection was recognized only in women, but actually it is passed back and forth quite easily between sex partners. New diagnostic tests may make it easier for people who are infected to get tested and treated along with their partners,” Dr Meites said. 

	Key updates to the trichomoniasis section in the new 

 pertain to current epidemiology, guidance on the use of novel diagnostic methods, identification of high-risk groups, and treatment recommendations for HIV-infected patients.

 infection is estimated to affect 3.7 million women and men in the United States, but there are disparities in its prevalence by race/ethnicity and age. 

 infection affects 13% of black women versus only 1.8% of non-Hispanic white women. In addition, unlike other non-viral STDs, a higher prevalence has been detected in older age groups (eg., >11% in women age ≥40). High prevalence of 

 infection has also been identified among persons presenting to sexually transmitted disease clinics, particularly symptomatic individuals, and people incarcerated in correctional institutions.

	According to the guidelines, decisions about screening might be informed by local epidemiology of 

 infection; screening might be considered for persons receiving care in high-prevalence settings and for asymptomatic persons at high risk. Routine screening and prompt treatment are recommended at least annually for all women with HIV infection. Testing for 

 is recommended for those who are symptomatic.

	Regarding diagnosis, the 2015 guidelines identify nucleic acid amplification tests (Aptima 

 Amplified DNA Assay, BD; and others) and same-day or point-of-care tests (OSOM Trichomonas Rapid Test, Sekisui Diagnostics; Affirm VP III, BD) as newly available methods that can be conducted on a variety of specimens, potentially allowing highly sensitive testing and screening of both women and men at risk for infection.

	For treatment of trichomoniasis, single-dose therapy with an appropriate nitroimidazole antibiotic (ie, metronidazole 2 g or tinidazole 2 g) remains the recommended regimen. Based on results of a randomized clinical trial conducted among HIV-infected women, however, the current guidelines recommend that women who are also infected with HIV should be treated with a longer 7-day course of metronidazole 500 mg twice daily.

	1. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. ‎Sexually Transmitted Diseases Guidelines, 2015. 

. 2015;64(RR-03):1-137. Available at: http://www.cdc.gov/std/tg2015.

	2. Meites E, Gaydos CA, Hobbs MM, et al. A review of evidence-based care of symptomatic trichomoniasis and asymptomatic 

Trichomoniasis: the "neglected" sexually transmitted disease.

	4. Secor WE, Meites E, Starr MC, Workowski KA. Neglected parasitic infections in the United States: trichomoniasis. 

	5. Hoots BE, Peterman TA, Torrone EA, Weinstock H, Meites E, Bolan GA. A Trich-y question: should 

Articles

The CDC recently updated guidelines for treatment, but this common STI is considered "neglected" by some experts.

Trichomoniasis update

	Vaginal self-sampling using a proprietary device (HerSwab) gets high ratings from users and represents a suitable method for the diagnosis of 

 infections, according to the findings of a recently published study that compared the HerSwab with physician-collected vaginal samples.

	The device, which is still investigational in the United States, was developed for sexually transmitted infection (STI) screening. It allows for self-collection of vaginal samples that are transported dry inside the device, to a laboratory for analysis.

	“Screening programs are in place to detect and treat STIs in the lower genital tract as these infections may be asymptomatic and ascend into the upper tract, causing complications. Because of privacy concerns and a variety of other reasons, teenage girls and women may be reluctant to undergo specimen collection performed by a healthcare provider,” said Max A Chernesky, PhD, senior author and professor emeritus, Departments of Pediatrics, and Pathology and Molecular Medicine, McMaster University.

	“Our assessment of the self-collection device indicates it is a viable option for overcoming this barrier to STI screening."  Larger studies are needed to evaluate the accuracy of the self-collected specimens.

	The study evaluating patient acceptance and the diagnostic performance of the self-sampling device was conducted by researchers at St. Joseph’s Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada, and published in the February 2016 issue of 

	It included 189 women ages 16 to 41 years who were recruited from a street youth clinic or therapeutic abortion clinic. All women performed self-collection and underwent physician sampling using a commercially available product that uses specimen transport media (Aptima, Hologic). For each participant, the order of the two sampling techniques was determined by randomization.

	Analyses of responses from questionnaires completed by the study participants showed they were almost unanimous in considering the self-collection easy (97.1%). Most women also rated it as comfortable (88.3%), preferred self-collection over physician collection (80.9%), and said they would consider using the self-collection device at home (79.7%).

	Greater comfort was the leading reason cited for preferring the self-collection device. Of the minority of the participants who preferred physician collection, two-thirds expressed concern about collecting an inadequate sample.

 infection in 20 participants (10.6%) and 

 in 5 participants (2.6%). The self-collection method detected 4 more 

 infections than the physician collected method but the number of infections was too few to measure significance. Overall, there was a high level of agreement between the two methods for both 

	Additional analyses showed that participant’s positive impressions about the self-collection procedure were robust across a variety of individual characteristics. There were no significant relationships between ratings of either ease or comfort of use and presence of vaginal symptoms, history of an STI, the order in which specimen collection was performed, or the participant’s preference for the self-collection technique. In addition, preference for self-collection versus physician-collection was not associated with age or willingness to consider self-collection at home, and participants were similarly likely to consider self-collection at home whether or not they had a history of STI or current symptoms.

	Dr Chernesky noted that other research conducted by his group indicate that despite the absence of storage in transport media, specimen analysis remains accurate as long as the dry sample is processed within 7 days.

	“Avoiding the need for transport media may also increase user acceptance of this product considering that we have also learned that concern about spilling transport media on themselves is an issue some women raise with the use of other vaginal self-collection kits,” he said.

A self-sampling device being used in Canada is receiving high marks from patients.

Cheryl Guttman Krader, BS, Pharm

Articles

Trichomoniasis update

Vaginal self-sampling for STIs