Improving Diagnosis of Reproductive Tract infections in Rwandan Women: Feasibility, Acceptability, and Preliminary Effectiveness of an Evidence-based Diagnostic Algorithm

About This Grant

Global resurgence of curable sexually transmitted infections (STI) is a public health concern due to their severe associated morbidities and increasing antimicrobial resistance. Inadequate diagnosis leads to under- and overtreatment, fueling HIV/STI risk, antimicrobial resistance, and adverse fertility and pregnancy outcomes. To address this critical gap, the Center for Family Health Research in Rwanda and Emory colleagues developed and validated a CT/NG diagnostic algorithm for women informed by local epidemiology as recommended by WHO. Among symptomatic women seen at our clinic, our algorithm had a sensitivity of 79-91% versus 26% using the Rwandan National Guidelines. Formative work confirms providers can be trained to use our algorithm, though microscopy capacity requires development. Our proposal aims to implement and evaluate our algorithm, including microscopy, in public HC to improve RTI diagnosis in Rwandan women. Scientific rationale for conducting this work in Rwanda. Rwanda is uniquely suited to answer these questions faster and at lower cost than the US. STI burden in our Rwandan cohort (NG 26%, CT 16%) far exceeds US primary care rates, enabling adequate power at a fraction of the domestic sample size. Rwanda’s universal syndromic management policy provides a clearly defined comparator unavailable in the heterogeneous US system. Finally, PI Wall’s decade-long CFHR partnership and existing algorithm validation means work can begin immediately with infrastructure and community trust in place. We will first conduct stakeholder interviews and needs assessments guided by an implementation science framework in 4 HC to understand perceptions, barriers, and facilitators to implementing our algorithm with microscopy (Aim 1). Based on Aim 1 findings, we will co-design training and quality assurance protocols and pilot our algorithm with microscopy using a self-controlled case series design among 310 women in 4 Rwandan HC (Aim 2). The REAIM framework will guide evaluation of algorithm with microscopy feasibility, acceptability, and preliminary effectiveness (Aim 3). Study findings will be shared with high-level stakeholders throughout the study to solicit feedback to inform future studies and for public health impact. Although conducted in Rwanda, this work directly advances the health of Americans: STI prevalence in high-burden US communities approaches Rwandan levels, microscopy for RTI diagnosis is similarly underutilized in US primary care, and the validated diagnostic algorithm and implementation package developed here can be directly applied and utilized across the United States to offer expanded and enhanced care to Americans for whom comprehensive STI testing in pregnancy and primary care remains out of reach, such as in rural communities and for individuals in urban areas that do not routinely access primary or preventive health care.