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...

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