[ARCHIVED] Adherence & Retention

Hi Adherence and Retention Community,

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I hope members who have experience with community health workers and diagnostics will consider sharing their thoughts on Dr. Lester Hartman's posting. Dr. Hartman has also posted a bit about this topic in our Malaria Treatment and Prevention community (http://www.ghdonline.org/malaria/discussion/rdts-in-hiv-and-malaria/), but perhaps he will be able to share more detail about his work with us here as well.

We look forward to hearing everyone's thoughts on this issue, and hope we can continue this and all discussions in a collegial manner.

Many thanks,
Jessica Haberer, MD, MS
GHDonline Adherence & Retention Community Moderator

I apologize that I could not attach the strep poster. When smart phones become cheap imagine what potentional there could be for self care . On my office website if you go to www.wmpeds.com and parent education patient videos in the red tabs on the left column of the homepage, there are 2 You Tube Videos one on how to perform the swabbing of the throat (with a processing the swab video attached) and a video when a sore throat is a sore throat but someone worse. THis can be a scary notion to physicians but imagine how we could reprioritize our days if there was a significant reduction in visits for rule out malaria when there is a fever and a not particually ill child. In the US, 65%-75% of the strep test performed in my office are negative.

Dr. Hartman, I find this to be a very compelling topic. I haven't heard of the strep tests being used by families or CHWs, but there has been lots of similar conversation around the use of rapid HPV and HIV testing. One caveat is that self-collected HPV samples are shown to be helpful, though less sensitive than clinician/provider-collected samples. I imagine this would be similar to that of strep testing, whereas rapid HIV testing requires less clinical skill (saliva or finger prick). Do you know of any studies that show the sensitivity/specificity of rapid strep tests collected by non-health care professionals? Also, can you provide the false positive and false negative rates of this particular rapid strep test? As a primary care provider, I can sympathize. If there was a cheap and simple RDT to rule out bacterial infections vs common cold/viral syndromes it would open up a considerable amount of clinic time for those with more serious illnesses. And as a health care professional initially trained at the Berkeley Free Clinic in California, I'm all for putting more tools/control into the hands of families and community members. My hope would be to add ...

Dr. Hartman, I find this to be a very compelling topic. I haven't heard of the strep tests being used by families or CHWs, but there has been lots of similar conversation around the use of rapid HPV and HIV testing. One caveat is that self-collected HPV samples are shown to be helpful, though less sensitive than clinician/provider-collected samples. I imagine this would be similar to that of strep testing, whereas rapid HIV testing requires less clinical skill (saliva or finger prick). Do you know of any studies that show the sensitivity/specificity of rapid strep tests collected by non-health care professionals? Also, can you provide the false positive and false negative rates of this particular rapid strep test? As a primary care provider, I can sympathize. If there was a cheap and simple RDT to rule out bacterial infections vs common cold/viral syndromes it would open up a considerable amount of clinic time for those with more serious illnesses. And as a health care professional initially trained at the Berkeley Free Clinic in California, I'm all for putting more tools/control into the hands of families and community members. My hope would be to add affordable RDTs for hepatitis, gonorrhea and chlamydia. I do think, though, that the education and counseling component needs to be stressed and reinforced. Given the relatively greater prevalence of rheumatic heart disease in low and middle income countries (vs the US), what are the implications of families and CHWs using rapid strep tests in places such as Haiti (vs suburban Massachusetts)?

I applaud the attempts to increase access to testing but agree that we need to consider test and performance characteristics. I agree that it would be helpful to see data indicating test performance characteristics with untrained users for collection and processing. The manufacturer of Quickvue reports sensitivity of 87% and specificity of 94% and some variability when done in office labs http://www.quidel.com/libraries/nccls/RD/QuickVueInLineStrepA.pdf There is some data in the literature that strep testing is less accurate when processed outside of the lab. I am not a pediatrician but it is my understanding that, many (but not all) guidelines (including the rapid strep manufacturer/FDA) recommend that negative rapid strep tests in children be followed-up with a culture. If that is the case both positive and negative results would result in a visit so the benefit is less clear in the US. In a setting where culture is not available, the issues may be different. With HIV testing, just recently approved, there is data on untrained users which shows reasonable performance characteristics (although not perfect) and this is included in the package insert. However, the test approved by the FDA is the oral test ...

I applaud the attempts to increase access to testing but agree that we need to consider test and performance characteristics. I agree that it would be helpful to see data indicating test performance characteristics with untrained users for collection and processing. The manufacturer of Quickvue reports sensitivity of 87% and specificity of 94% and some variability when done in office labs http://www.quidel.com/libraries/nccls/RD/QuickVueInLineStrepA.pdf There is some data in the literature that strep testing is less accurate when processed outside of the lab. I am not a pediatrician but it is my understanding that, many (but not all) guidelines (including the rapid strep manufacturer/FDA) recommend that negative rapid strep tests in children be followed-up with a culture. If that is the case both positive and negative results would result in a visit so the benefit is less clear in the US. In a setting where culture is not available, the issues may be different. With HIV testing, just recently approved, there is data on untrained users which shows reasonable performance characteristics (although not perfect) and this is included in the package insert. However, the test approved by the FDA is the oral test which has slightly lower sensitivity than the blood test. In a low prevalence population this results in lower PPV. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70368-1/abs... Our center stopped offering the oral test several years ago because of sensitivity concerns. There may still be benefits of getting the tests directly into the hands of consumers and I support home HIV testing but I think we need to understand the limitations of the test as well.