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NCSD’s Comments to USPSTF

Proposed Analytic Framework

In USPSTF’s proposed analytic framework an arrow between reduced transmission and acquisition and reducing maternal and, fetal, or infant outcomes, however, perinatal transmission and pregnancy outcomes get lumped into one of the many outcomes for key question one under the research approach section. NCSD suggests creating a separate question for pregnancy-related and perinatal outcomes, or adding it as a second question to the Proposed Contextual Question section.

Proposed Key Questions to Be Systematically Reviewed

1. In sexually active, asymptomatic adolescents and adults, including those who are pregnant, what is the effectiveness of screening for chlamydial and gonococcal infections in reducing complications of infection and transmission or acquisition of disease, including gonorrhea, chlamydia, and HIV?

• NCSD recommends making this two separate questions to make it more effective:
  • To what extent does screening reduce non-infectious long term sequelae, specifically PID, ectopic pregnancy, infertility, chronic pelvic pain, and epididymitis? As this is already included in the outcomes section, key question one in the Proposed Research Approach, it will assist with consistency.
  • To what extent does screening reduce transmission and acquisition of infectious disease including gonorrhea and chlamydia?

2. What is the effectiveness of risk stratification methods or alternative screening strategies for identifying persons who are at increased risk for chlamydial and gonococcal infections (such as those

who are younger, men who have sex with men)? Screening strategies include co-testing for concurrent sexually transmitted infections, including HIV, or using different screening intervals.

• NCSD is in favor of co-testing for appropriate potential concurrent STI including, however, we recommend including syphilis and HIV explicitly in this question.

3. What is the diagnostic accuracy of anatomic site–specific testing and self-collected swabs for identifying persons with chlamydial and gonococcal infections?

1. • NCSD recommends that the term “diagnostic accuracy” be clearly defined and include sensitivity and specificity of a diagnostic method. It is not clear from the question what is being assessed, whether it is the diagnostic accuracy of the test or accuracy of the test at a particular site. It is also unclear from the key questions or proposed research question which methods will be assessed
   • NCSD recommends that for “anatomic site-specific testing,” urine, endocervix, urethra, vagina, anus, pharynx be specified within the question. As this is already included in the intervention section of the Proposed Research Approach section, it will assist with consistency.
   • Due to the differentiation between anatomic sites and treatment in the Proposed Research Plan, it would make sense to include a sub-question to key question three to address the treatment efficacy of the gonococcal and/or chlamydial infection(s) at the different sites.

Research Approach

NCSD recommends that instead of excluding participants who use PrEP, they should be considered as part of the “risk stratified” group for key question two. This research approach does not exclude participants at risk for HIV who use other methods of HIV prophylaxis, such as condoms, it is important to remain consistent.