Point-of-care testing and treatment of sexually transmitted infections to improve birth outcomes in high-burden, low-income settings: Study protocol for a cluster randomized crossover trial (the WANTAIM Trial, Papua New Guinea)

Andrew Vallely ,Nicola Low,Leanne J Robinson,Neha Batura,Elizabeth Peach,Grace Kariwiga,David M Whiley,Sepehr N Tabrizi,Handan Wand,Caroline Homer,Peter Siba,Stephen J Rogerson,John Bolnga,Rebecca Guy,Virginia Wiseman,Delly Babona,Moses Laman,Chris Morgan,Suzanne M Garland,Jacob Morewaya,W.f Peter ,Lisa M Vallely ,William Pomat ,Glen Mola ,Angela Kelly‐Hanku ,Steven G Badman ,Stanley Lüchters ,Pamela J Toliman ,Rosanna W Peeling ,Michaela A Riddell ,John Kaldor

doi:10.12688/wellcomeopenres.15173.1

Abstract

Background: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and bacterial vaginosis have been associated with preterm birth and low birth weight, and are highly prevalent among pregnant women in many low- and middle-income settings. There is conflicting evidence on the potential benefits of screening and treating these infections in pregnancy. Newly available diagnostic technologies make it possible, for the first time, to conduct definitive field trials to fill this knowledge gap. The primary aim of this study is to evaluate whether antenatal point-of-care testing and immediate treatment of these curable sexually transmitted and genital infections (STIs) leads to reduction in preterm birth and low birth weight. Methods: The Women and Newborn Trial of Antenatal Interventions and Management (WANTAIM) is a cluster-randomised crossover trial in Papua New Guinea to compare point-of-care STI testing and immediate treatment with standard antenatal care (which includes the WHO-endorsed STI ‘syndromic’ management strategy based on clinical features alone without laboratory confirmation). The unit of randomisation is a primary health care facility and its catchment communities. The primary outcome is a composite measure of two events: the proportion of women and their newborns in each trial arm, who experience either preterm birth (delivery <37 completed weeks of gestation as determined by ultrasound) and/or low birth weight (<2500 g measured within 72 hours of birth). The trial will also evaluate neonatal outcomes, as well as the cost-effectiveness, acceptability and health system requirements of this strategy, compared with standard care. Conclusions: WANTAIM is the first randomised trial to evaluate the effectiveness, cost-effectiveness, acceptability and health system requirements of point-of-care STI testing and treatment to improve birth outcomes in high-burden settings. If the intervention is proven to have an impact, the trial will hasten access to these technologies and could improve maternal and neonatal health in high-burden settings worldwide. Registration: ISRCTN37134032.

Highlights

Every year there are an estimated 2.6 million stillbirths and 2.6 million neonatal deaths globally; the majority are in low- and middle-income countries (LMIC), primarily in remote and rural communities[1]
In a meta-analysis, we found that trichomonas is associated with a relative risk of 1.4 (95%Chief Investigator (CI): 1.1-1.7) for preterm birth[27], and is linked to low birth weight and premature rupture of membranes
Building on the experience from the Test Treat ANd GO (TTANGO) Trial[37] in remote Aboriginal communities in Australia, we showed the feasibility of point-of-care sexually transmitted and genital infections (STIs) testing and treatment in a pilot study in selected antenatal settings in PNG37,38

Summary

Introduction

Background Every year there are an estimated 2.6 million stillbirths and 2.6 million neonatal deaths globally; the majority are in low- and middle-income countries (LMIC), primarily in remote and rural communities[1]. Preterm birth and low birth weight are closely linked, as well as being independent and major contributors to neonatal mortality Together, they affect around 20% of newborns in PNG4. Syphilis treatment is most effective in the early gestation period, and later treatment may not reverse damages to the fetus Relate this to the importance of the timing of ANC visits and how this might affect the outcomes if early visits are not promoted in conjunction with the testing strategy. The primary aim of this study is to evaluate whether antenatal point-of-care testing and immediate treatment of these curable sexually transmitted and genital infections (STIs) leads to reduction in preterm birth and low birth weight. Conclusions: WANTAIM is the first randomised trial to evaluate the effectiveness, cost-effectiveness, acceptability and health system requirements of point-of-care STI testing and treatment to improve birth outcomes in high-burden settings.

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