The field of STI diagnostics in Italy sees only certain regions covered by cohesive plans for examination, diagnosis, treatment and prevention. More needs to be done if patients are to receive better diagnostics and improved management.
Dr Maria Agnese Latino knows this all too well; having managed a centre for the diagnosis and treatment of STIs between 1989 and 2014, she is now engaged in advising and coordinating the STI working group of the Italian Association for Clinical Microbiology, GLIST. Latino is also interested in diagnostic techniques, public health work and the latest patient care schemes for patients undergoing treatment for STIs.
Latino also trains others to improve their skills. With members of the STI working group, she offers courses on diagnostic pathways and management of STIs (such as male urethritis, vaginitis and cervicitis, and STIs in pregnancy), and single subject courses on STIs (such as chlamydia and syphilis) in conjunction with the organisers of the permanent training course 'Diagnostics pathways and management of Sexually Transmitted infections', in collaboration with the International Union against Sexually Transmitted Infections. The course is held biannually in Bertinoro, Italy, with the next event scheduled for June 2018.
Latino has worked in STI services in Italy for many years and believes it reflects many trends in other countries, especially for patient care.
"I think the main challenge is that centres for sexual health must be created that are capable of managing not only STIs, but also other situations, such as contraception, pregnancy and sexual abuse," she says.
Major challenges for STI centres include increasing the number, quality and availability of prevention, diagnosis and treatment services. Other key challenges include the use of shared guidelines; the integration of primary services between those for reproduction and those for improving the total care of patients with HIV; integrating public and private centres; and improving the use of these centres to give people easy access without facing stigma or financial obstacles.
Latino has a strong understanding of STIs that the general public and at-risk groups often know less about, and understands which areas need higher prioritisation.
"Chlamydia infections are at the forefront because they often take effect with no symptoms at all," she says. "Incidence is increasing among young people under 25, and chlamydia is responsible for the highest number of complications and consequences - particularly for women's fertility. It represents the greatest cause of pelvic inflammatory disease and tubal infertility."
Among the areas of growing awareness is the recent rise in interest in bacterial vaginosis (BV), for which the consequences of a missed diagnosis are also serious.
"Diagnosis is essential since BV can lead to gynaecological, obstetric and significant neonatal complications, such as miscarriage, preterm delivery, low neonatal weight, post-miscarriage or post-partum endometritis, and an increased susceptibility to other STIs." For these reasons, Latino says, correct treatment of the patient is of utmost importance, particularly in pregnant patients.
Latino is also interested in testing trends and areas that could be improved. She comments that, in an ideal future, "it would be desirable to have rapid molecular tests that permit the diagnosis of chlamydia, gonorrhoea and Mycoplasma genitalium within 30-45 minutes".
"Additionally," she says, "the use of nucleic acid amplification tests (NAATs) is increasing significantly and, in particular, the use of multiplex NAATs. I think that things will take off in this direction. It is important to improve point-of-care testing (POCT) to enable immediate diagnosis."
Latino says POCT is useful in managing patients because it saves having to recall positive patients for treatment. Instead, treatment can be administered immediately, raising patient compliance and reducing the spread of infection.
POCT available for HIV, hepatitis C, syphilis, trichomoniasis and BV has been shown to be effective, but needs to be used more widely: "Wider adoption in Italy of POCT would be an advantage. Unfortunately, however, not all STIs have POCT available that meets all of WHO's ASSURED criteria."
STIs can often lead to complications and very serious sequelae, in the short and long term. This is a key reason why the choice of diagnostic tools is so important.