Laboratory Procedure Courses National Network of Prevention Training Centers Linda Creegan, MS, FNP California STD/HIV Prevention Training Center Oakland, CA National STD Prevention Conference Chicago, March 2008

CLINICIANS….. Are you new to the STD clinic? Is your clinic starting to use a new test? Herpes? Trichomoniasis? Bacterial Vaginosis? Syphilis? Rapid HIV test? Darkfield microscopy?

Enroll in an NNPTC laboratory procedure course!! Tests for STD specialty clinics Syphilis tests Gram stains Saline and KOH wet mounts Point-of-Care (POC) tests for STD

Tests for STD Specialty Clinics

Syphilis Tests Serologic tests for syphilis Darkfield microscopy Learn to perform and interpret the qualitative RPR test Darkfield microscopy Learn to Obtain the specimen Use the microscope Identify T. pallidum by morphology and motility

Utility of Rapid RPR Test Evaluation of patients with symptoms of primary and secondary syphilis Facilitates immediate diagnosis, treatment, and initiation of partner management activities

Darkfield Microscopy Photo credit: Dr. Joseph Engelman, San Francisco City Clinic

Identifying T. pallidum by DF Morphology Rigid, uniform, tightly-wound spirals Tight coil is maintained despite active motility Length: 6-20 micrometers Width: VERY thin 0.10-0.18 micrometers, below the resolution of the light microscope Motility Exhibits three types of movement Translation: slow, forward or backwards movement Rotation: turning around the longitudinal axis Flexion: stiff bending, usually in the middle, and returning to original position

Gram Stains Male urethral discharge, cervical and rectal specimens Learn to Obtain the specimen Identify WBCs and GNID Diagnose gonococcal vs non-gonococcal urethritis STD Atlas, 1997

Saline and KOH Wet Mounts Vaginal specimens Learn to Obtain the specimen Use the microscope Identify findings (Clue cells, yeast forms, trichomonads) Diagnose BV, yeast, trich Photo credit: Seattle STD/HIV Prevention Training Center

Point-of-Care Tests for STD

What are Point-of-Care tests? Rapid diagnostic tests Run in clinic or field setting Very easy to perform Usually require only microscope or simple lab equipment Often CLIA waived Provide results at same clinic visit Diagnostic and screening applications Probably most of the tests we order are sent to a lab, and the results come back to us on a delayed basis. However, point-of-care tests are available for some STDs. These are tests that are run on-site by the clinician or other staff, and provide results in a short period of time.

Point-of-Care STD Tests: A Paradox Generally not as sensitive as delayed lab tests In populations where patients are less likely to return for results or F/U is difficult, higher treatment levels can be achieved with POC than with delayed tests Homeless clinics Emergency rooms Correctional facilities However, these point-of care tests are generally less sensitive and/or specific than are the lab-based tests. So why would any clinician want to use a less sensitive test? Well, if your population is not likely to return in a week for results, or if follow-up on the clinic’s end is going to be time-intensive and difficult, higher levels of treatment can actually be achieved using POCs, and getting the result while the patient is there with you, than risking the loss to follow-up. So these tests could be especially useful with homeless patients, in ERs, or in jails, where patients are often released before a test result comes back from the lab.

Point-of-Care Test Courses Learn about Lab regulatory issues (CLIA) POC tests for genital herpes, vaginitis, syphilis, CT and GC, and HIV Obtaining specimens Using test kits Interpreting results Maintaining quality assurance