HIVreport
HIVreport.de012012Rapid tests2Counselling and Testing5Controversy over rapid tests8Demonised in the past –Today a preventive toolaidshilfe.de
HIVreport 1/2012: Rapid TestsIssue No. 01/201214/03/2012Dear Readers,RAPID TESTSToday’s guidelines suggest that HIVinfection should be diagnosed before thereare any symptoms in order to be able tostart antiretroviral therapy in time.COUNSELLING AND TESTING . 2CONTROVERSY OVER RAPID TESTS . 5As we know from the PARIS study published in 2001 (HIVreport 06/2011), othersexually transmitted infections (STIs) suchas gonorrhoea, chlamydial infection orsyphilis are not only common in gay men,but also show little to no symptoms.The statement by the DSTIG, RKI and PEIon STI rapid tests . 5The statement on the statement . 5The same goes for HCV infections in drugusers: Damage in the body often does notbecome apparent until years later.DEMONISED IN THE PAST – TODAY APREVENTIVE TOOL . 8In all these cases, it is essential to offercounselling and testing options for seemingly healthy persons who are at an increased risk of HIV or HCV infection orother STIs.References . 10Imprint . 11Testing projects and health authorities areincreasingly using rapid tests to lower thethreshold for asymptomatic persons to seekcounselling and testing.However, the use of rapid tests has alsosparked criticism. In early February, a critical statement on STI rapid tests was released by the German STI Society (DSTIG)in cooperation with the Robert Koch Institute (RKI) and the Paul Ehrlich Institute(PEI).In this HIVreport, we report about the experiences in the testing projects and take acloser look at the DSTIG’s position paper.Enjoy reading!Steffen Taubert and Armin Schafberger1
HIVreport 1/2012: Rapid TestsCounselling and testingWhy get tested?and prevention projects offered counsellingand testing in more than 50 German cities,backed by national advertising.Germany’s STI and HIV diagnostics are inrough shape.The testing weekswerescientificallyevaluated,focusingon stationary testingprojects in 2009 andon mobile testing facilities, e.g. in parkinglots and saunas, in2010 (Drewes 2011,Sadlowski 2011). Mentested by AIDS serviceorganisationsshowed a high prevalence of HIV, accountingfor 2.5%.Compared to other European countries, thereis a lack of suitable HIV and STI counsellingand testing options for gay men and otherMSM (Schmidt 2011).This has consequences: The RKI’s 2011PARIS study found rectal and/or pharyngealchlamydia and/or gonococci (Neisseria gonorrhoeae) in more than 14 % of all male subjects.The RKI estimates that 20 % of the 73,000people living with HIV are still undiagnosed.In approx. 1,000 of the 2,889 HIV diagnosesreported in 2011, the HIV infection was already at an advanced stage 1 (RKI 2011). Thesituation was similar during the years 2001–2012: 49.5 % of the 22,925 people diagnosedwere late presenters, i.e. their diagnosis wasmade at a stage where the CD4 cell countwas already below 350/µl and/or AIDSdefining symptoms were present (Zoufaly2012). The ideal time to start therapy hadbeen missed. This indicates the need for action.A large number of projects have incorporated counselling andtesting as part of theirstandard service, orhave expanded existing services. Nationaltesting weeks are currently being plannedagain for 2013.Drug usersGay men and other MSMMany physicians who provide medical carefor intravenous drug users offer hardly anyHIV and HCV tests. Two counselling centres,“Fixpunkt” in Berlin and “KICK” in Dortmund,launched the project “TEST IT”, offeringcounselling and HIV rapid tests.Deutsche AIDS-Hilfe (DAH, German AIDSService Organisation) recommends that sexually active gay men and other MSM get tested at least once a year for HIV, syphilis andgonococci as well as chlamydia; those withmore than ten sexual partners should gettested twice a year for syphilis, gonococciand chlamydia.Motivation for HIV Testing at DortmundAIDS Service Organisation (KICK)1%Not specifiedOtherIn 2009 and 2010, testing weeks took placeas part of a prevention campaign entitled“ICH WEISS WAS ICH TU” (IWWIT) (“I knowwhat I’m doing”). AIDS service organisations14%Test is easy to doHowever, medical practices and otherhealthcare facilities provide inadequate counselling and testing for gay men. This is whyAIDS service organisations and Checkpointsare increasingly offering counselling and testing services.37%58%Test alsoavailable at otherfacilitySurvey among the first clients of the Dortmund HIVrapid test service: The test’s ease of use was reported as the biggest motivational factor. Only 1%Clinical AIDS and/or CD4 cell count 200/µl.2
HIVreport 1/2012: Rapid Testswould take the test at another facility: trust and anonymity is important (see HIVreport 02/2010).StandardsSince 2008, a national study group of AIDSservice organisation staff has developed minimum standards for testing projects, whichhave been published in the “HIV and STITests” brochure to provide comprehensiveguidelines on process management, anonymity, counselling, testing (including rapid tests)and communicating test results.Both projects saw great demand for hepatitisC counselling, which prompted them to incorporate HCV rapid tests into their range ofservices.Education and informationThe AIDS service organisations have offeredHIV, hepatitis and STI counselling and information since their inception. HIV and STItesting services, however, are still relativelynew at many facilities. A variety of collaborative partnerships have been developed byhealth authorities and AIDS service organisations/Checkpoints in cities like Hamburg(CASA blanca/Hein & Fiete) or Munich(health authorities/AIDS service organisation). Various facilities in other cities, including Cologne and Berlin, employ laboratoryprofessionals as well as registered or independent physicians to provide testing services on an hourly basis.Counselling and prevention as top prioritiesThe information and standards provided indicate the significance of counselling and riskevaluation in our testing services. Whetherit’s for laboratory or rapid testing, test counselling is designed to give clients feedback totheir personal risk management. After all, 97% of our clients leave the facility with an HIVnegative result. Counselling is meant to contribute to maintaining this result in the future.This way, testing services can also provide alasting benefit in prevention.In addition to its traditional counsellor trainingprogrammes, Deutsche AIDS-Hilfe now alsooffers a wide range of seminars and information on testing facilities and the use oftests. Its national head office reviews available scientific literature on the quality of rapidtests and recommends that its member organisations only use rapid tests that havebeen confirmed to be reliable by independentscientific studies, as stated in the recentlyupdated brochure “HIV and STI Tests: Information and Standards 2012/2013”.Clients with an HIV- or STI-positive result receive detailed advice on their new circumstances and are immediately referred, andoften accompanied, to qualified specialists.Armin Schafberger3
HIVreport 1/2012: Rapid TestsPros and cons of rapid testsNot all testing projects of AIDS service organisations use rapid tests: The pros and consbasically balance each other out. Whether ornot rapid tests can be used purposefully ultimately depends on the local circumstancesand the judgement of the responsible physician.Pros When using rapid tests, pre- and post-testcounselling is conducted by the samecounsellor who, when communicating testresults, can pick up where the pre-testcounselling session left off to review theprevious assessment of risk management.Oraquick: This HIV test can be performed usingcapillary blood, serum or oral fluid. While the useof oral fluid is very common in the United States, itis still a controversial subject in Germany. There is no long wait for the test-taker between giving a blood sample and receivingthe test result. Anxious or overly optimisticthoughts (“I’m sure it’s fine”) during thewaiting period may lead to clients not returning for their test results. No second appointment is needed to receive the result: Rapid tests simplify thetesting procedure, especially for those whoare advised to take two or more syphilistests a year due to their number of partners. HIV and HCV rapid tests do not require avenous blood sample, which lowers thethreshold for many clients to seek testing.Rapid tests do not involve venepuncture,which is often difficult to perform in injectiondrug users.Cons Rapid tests always have a slightly lowersensitivity and specificity than laboratorytests. Rapid tests usually detect recent infections(during the window period) several dayslater than an equivalent laboratory test. If arecent infection is suspected, the testingprojects use laboratory tests or refer theirclients to registered physicians. Rapid testing is staff-intensive; venousblood sampling is easier to perform.The fastest among HIV rapid tests: INSTI bybioLytical Laboratories produces resultswithin less than a minute. But is that good forcounselling?Thetestwasrecently(re-)introduced to the market. There are fewer control procedures andquality assurance measures such as interlaboratory tests. An EU directive is expected to raise these standards in the nextfew years.Photos: Schafberger (top, bottom)4
HIVreport 1/2012: Rapid TestsControversy over rapid testsThe high sensitivity of the Determine syphilistest has been confirmed by the results of arecent evaluation by the Krone syphilis reference laboratory in Bad Salzuflen (Hagedorn2012). In a panel of 818 samples, the rapidtest detected all 32 positive samples (100 %sensitivity), with eight samples being falsepositive (99 % specificity). In another examination of 211 seropositive samples fromsyphilis patients, the test detected 205 samples (97.2 % sensitivity); the false-negativefindings “are usually associated with residualfindings following a previous treponema infection”. After a resolved or treated syphilis infection, the antibody level goes down as theyears pass, which can make things difficultfor the rapid test. However, the clients’ conditions in these cases were not acute or inneed of treatment.The statement by the DSTIG, RKI and PEIon STI rapid testsTogether with the RKI and the medicalregulatory body PEI, the German STI Society (DSTIG) composed a statement onthe reliability of STI rapid tests, releasedin the Epidemiological Bulletin No. 5 of 6February 2012 (Bremer 2012).The authors see the use of rapid tests as away to facilitate access to STI diagnostics,while pointing out that such tests often havelower sensitivity and specificity compared tostandard methods. The quality of severalHCV rapid tests and one HCV rapid test metwith their approval (except when used withoral fluid). They advise against using rapidtests for the diagnosis of syphilis or chlamydia, gonorrhoea and HBV infections.The statement on the statementSince the testing projects of AIDS serviceorganisations and drug programmes donot use rapid tests for chlamydia, gonorrhoea and HBV, the controversy is focused on the use of syphilis rapid tests –and will soon also concern the use of oralfluid as a sampling material for HIV andHCV tests. Below, we give our views onthe statement by the DSTIG, RKI and PEI.Syphilis rapid testsIn the statement by the DSTIG, RKI and PEI,lower sensitivity is listed as the primary reason not to use syphilis rapid tests. Their evaluation lumps together various syphilis rapidtests. As a matter of fact, there are severalsyphilis rapid tests that do have a noticeablylower sensitivity and specificity, and aretherefore not used in the testing projects ofDeutsche AIDS-Hilfe. The Determine test byAlere, however, is well evaluated and hasshown superior sensitivity and specificity inscientific studies compared to other rapidtests. The test’s sensitivity was 81.9 % (Li2009) to 88 % (Siedner 2004) in whole blood,and 97.2 % (Herring 2006) to 100 % (Li 2009)in serum, compared to laboratory diagnostics.Counselling and testing services in BerlinThe sensitivity levels in serum (97.2–100 %)are perfectly acceptable in our opinion. Thestatement by the DSTIG, RKI and PEI, however, fails to mention that serum can also beobtained in “low-threshold settings”.Deutsche AIDS-Hilfe recommends that itstesting projects use serum instead ofwhole blood when using the Determinesyphilis rapid test.5
HIVreport 1/2012: Rapid TestsAlmost all clients who take part in the testingprojects rightfully expect a negative test result. Anyone who thinks he/she may havecontracted HIV or acute syphilis (or is experiencing symptoms) had better go to a registered physician, health authority or outpatientclinic in any event – and would be referredthere by the testing projects.Sample calculation: Assuming a high prevalence (e.g. 2 %) of syphilis requiring treatment, a rapid test with a sensitivity of 98 %would miss only one of 50 syphilis cases in2,500 subjects.PARIS study: Syphilis antibodies andstages of infection6The statement by the DSTIG, RKI and PEIelaborates as follows: “There is a commonmisconception among users that it is not necessary to wait until the window period is overwhen using rapid tests.” We cannot understand how such a false notion came about,given that any medical diagnostic proceduremust be performed under the supervision andon authority of a physician in accordance withSection 24 of the German Infectious DiseaseControl Act (IfSG). We are not aware of anyphysician – or any counsellor in the testingprojects – who is not familiar with the concepts of incubation period and window period.Primary lesion32 positive64720 Latency periodsyphilisantibodiesnegative2 Secondary stage2Tertiary stage2 resolved/treatedIllegal diagnostics?In the statement by the DSTIG, RKI and PEI,rapid tests that are approved in Europe arelisted and evaluated in the same breath with:PARIS study: 32 of 679 ( 5%) HIV-negative MSMhad syphilis antibodies in their blood. After rapidtesting, a blood sample is taken for evaluation: 30subjects, i.e. 4.4 %, had syphilis requiring treatment(20 in the latency period, 6 at primary stage, 2 atsecondary stage, 2 at tertiary stage). Only two subjects had a resolved syphilis infection. The test isnot capable of distinguishing between “old” and“acute” syphilis. Bottom line: Rapid tests are asuitable choice for use in HIV-negative MSM. rapid tests that are not approved in Europe,and rapid tests offered on the Internet.Such an approach puts the physicians of testing projects and healthcare facilities, whichuse approved medical devices, in the samecategory as black-market and illegal activities.Window periodThe statement by the DSTIG, RKI and PEIrepeatedly points out that rapid tests detect arecent infection slightly later than a laboratorytest; in the case of HIV, there is a “delay” ofone week, which was described as a “significant” disadvantage.HIV and STI diagnostics are reserved forphysicians in accordance with Section 24 ofthe IfSG. The sale of HIV tests is also regulated in Section 11 Clause 3a of the GermanMedical Devices Act: The release of test kitshas been restricted to authorities and physicians since 2009. This applies to the use ofrapid tests in both “low-threshold” and “highthreshold” projects.Rapid tests are not designed to detect an infection as early as possible. The following isparticularly the case with HIV infection: Negative results of any test (including laboratorytests) during the window period are not certain. The clients in the testing projects areregularly made aware of this fact –irrespective of whether rapid tests our laboratory tests are used.The sale of HIV home tests is thus illegal, asis using HIV or STI tests and rapid tests without a physician.6
HIVreport 1/2012: Rapid TestsTests with oral fluid?In Europe, one HIV and one HCV test byOraSure Technologies, Inc. are also approved for use with oral fluid (in addition toserum and capillary blood or whole blood).The statement by the DSTIG, RKI and PEIadvises against this specific use.In our education materials and seminars, we,too, recommend that rapid tests should preferably be performed using serum or capillaryblood, since the concentration of antibodies ishighest in serum, slightly lower in capillary orwhole blood, and lowest in oral fluid 2.Not without my doctor: Testing and rapid testingservices in the projects of AIDS service organisationsPhoto: Sean Prior/ClipdealerNevertheless, the Oraquick HIV test appearsto be more reliable than expected: A recentlypublished meta-analysis (Pai 2012) summarising various studies suggests that the sensitivity of oral fluid testing is about twopercentage points lower than that of bloodtesting (98.03 % in oral fluid vs. 99.68 % inblood). The specificity was similarly high(99.74 % vs. 99.91 %).Low-threshold but not low-qualityThe statement by DSTIG, RKI and PEI focuses primarily on “low-threshold” settings.While the authors do not specify what testsettings exactly they are referring to, it can beassumed that they mean testing services byAIDS service organisations. In this regard, itmust be noted that:Oral fluid testing is commonly used in theUnited States. Starting in autumn 2012, anEU project designed to evaluate communitybased testing practices in Europe (COBAT) isexpected to introduce the use of oral fluid HIVrapid tests in Germany as well. Rapid tests are not only offered by counselling centres, but are also used in medicalpractices and clinics. The statement doesnot give any opinion on these settings. The association of AIDS service organisations offers rapid tests at professionally organised and equipped counselling centres.Blood sampling, counselling services andtest evaluation are performed in compliancewith strict quality standards.Armin Schafberger In line with the standards of DeutscheAIDS-Hilfe (DAH 2012), rapid rests aregenerally not used in particularly lowthreshold settings, such as mobile projects(e.g. in parking lots and saunas), becausesuch environments often do not allow forqualified and protected communication ofresults.2Oral fluid is no saliva! In many cases – including thestatement by the DSTIG, RKI and PEI – the samplingmaterial and the testing procedure are mistakenly referred to as “saliva” and “saliva testing”. In actuality, oralswab rapid tests collect antibodies from the surface ofthe gums in what is commonly referred to as “oral fluid”.A more appropriate term for this type of testing wouldbe “oral mucosa testing”. In saliva, which is secreted bythe salivary glands, the concentration would be too lowfor testing. Dipping the swab into a “pool of saliva” inthe mouth or applying saliva to it would constitute amedical error that must be avoided.7
HIVreport 1/2012: Rapid TestsDemonised in the past – Today a preventive toolThe change in significance of rapid testsfor HIV diagnosticsBesides two drug consumption rooms, Fixpunkt also offers rapid testing in a mobiledrug consumption unit. This testing andcounselling service takes place on a bus thatis parked once a week at Berlin’s Zoo Station,a known hangout for drug users. “Our services have received very positive feedbackfrom users, who even braved winter weatherand -14 C to meet with us.”Many have demonised them for a long time:Rapid tests for HIV diagnostics. AIDS serviceorganisations were concerned that rapid testscould adversely affect the high quality standards of HIV diagnostics, including pre- andpost-test counselling services. Some peoplemight take a rapid test by themselves as akind of “home test kit” to quickly check theirhealth status before sexual contact. Criticsargue that the vast majority of users wouldthen not take account of such factors as thewindow period or the possibility of a falsereactive result. Additionally, there was the riskof improper use.Rapid self-tests (home test kits) are not approved in Germany for a reason. However,when performed in a controlled setting, rapidtests can be very useful. In recent years, anumber of AIDS and drug counselling centreshave started offering rapid tests for HIV aswell as some for HCV and syphilis. Thehealthcare professionals at the counsellingcentres have been pleased to see that thisservice encourages many people to get tested who otherwise would not have done so ata health authority or medical practice, whilealso providing an excellent opportunity forpersonalised counselling.Fixpunkt Berlin: Testing and counselling servicesfor drug users including HIV and hepatitis C rapidtests. The use of capillary blood avoids the difficulty of venous blood sampling in drug users.It is important for drug users to be able to gettested without having to justify their drug useand addiction. This is why the testing servicesin AIDS service organisations offer a majoradvantage: They are anonymous and takeplace in an environment that is accepting oftheir lifestyle. There is a similar situationwhen HIV and HCV transmission is related tosexuality. Organisations that are involved inthe community and accepting of the lifestyle,such as AIDS service organisations and gayand lesbian counselling centres, make it easier for people to talk about sexually transmitted infections.“I think rapid tests are agreat addition to ourrange of services”, saysRegina Mosdzen, thenurse in charge oftestingalongsidephysicianKerstinDettmar at “Fixpunkt”.Regina Mosdzen, fixpunktThis drug counselling centre has been offering HIV and HCV rapid testing at three Berlinlocations for a little over a year now. “Rapidtests give us a great opportunity to providepersonalised advice on risk reduction. I oftenlike to use the 30-minute wait between bloodsampling and test result for this purpose”, explains Mosdzen. “Some people think theyknow all the risks, and are often very surprised to learn from us that snorting drugs isa relevant risk factor for HCV transmission.”The Munich AIDS Service Organisation wasone of the first AIDS service organisations toinclude rapid testing into their range of services. The feedback has been consistentlypositive, indicating great satisfaction with theorganisation’s counselling services. According to a 2011 survey of 168 users by the Munich AIDS Service Organisation, 97 % of theirclients would return to the Munich AIDS Ser8
HIVreport 1/2012: Rapid Testsvice Organisation if they needed to take another HIV test. Despite the growing significance of other sexually transmitted infections,the survey also shows that HIV remains thegreatest concern among clients: 83 % of respondents exclusively took an HIV test.cility’s accepting and discrimination-free atmosphere.However,thesuccess of rapidtesting in AIDSservice organisations was nota given. “Rapidtests have longbeendemonised and therewere many reasons not to usethem”, says KarlLemmen, psychologist and officer for qualityChristopher Knoll, Munichassurance andpsychosocialsupport at Deutsche AIDS-Hilfe. “Having towait up to a week for a confirmed result usedto be seen as a chance for reflection.” It wasmore than just an opportunity for clients to reconsider if they really want to return for theirtest results. “Some experts also saw the waiting period as being helpful in making peoplethink about their own carelessness. Sometimes there was something almost sadisticabout it.”This is also because counsellors carefully decide which test is suitable for which person.For example, a syphilis antibody test is notsuitable for everyone, since it also detects antibodies that may indicate a resolved infection. For all syphilis-related concerns,counsellors always refer clients first to a general practitioner. “We recommend that sexually active men take a syphilis test once totwice a year. However, when it’s evident thata client doesn’t even have a general practitioner yet and would otherwise not get testedat all, we are prepared to offer a syphilis rapidtest“, explains psychologist Christopher Knoll,who is in charge of the “Checkpoint” testingservice of the Munich AIDS Service Organisation. He adds that this should always include educating clients about the limitationsof the test.Knoll sees the greatest benefit of the testingservice in providing an anchor for counsellingsessions about prevention. “The testing service is helpful in talking to people about sexand related risks”, says Knoll. A counsellingsession does not necessarily always lead to atest. “Sometimes we refuse to perform a test,for instance when we‘re under the impressionthat a client is suffering from hypochondria.”In that case, however, the request for testingcan be used as an opportunity for in-depthcounselling and may include a referral totherapeutic services.The advent of antiretroviral therapy alsochanged the significance of HIV testing. Being diagnosed with HIV may still be a distressing and traumatic experience in aperson’s life, but it is no longer seen as adeath sentence. This progress made AIDSservice organisations revise their approach totest settings. While there was great concernin the past that reactive results in rapid testsmay cause clients great anxiety and distressfor a number of days (until they receive theconfirmed test result), this is no longer thecase today. “It didn’t turn out to be a problemin practice”, says Christopher Knoll, addingthat HIV rapid tests have proved to be veryreliable for the Munich AIDS Service Organisation. The combination of risk assessmentusing a detailed questionnaire and subsequent one-on-one counselling ensures thatonly people who are really at risk will be tested. “So far, we’ve not had any false-positivetest results”, reports Knoll. The counsellorsagree on one thing: Rapid tests are a valuable addition to primary prevention. “Our rapidtesting service provides a structured approach to engaging in dialogue. When usingrapid tests, both pre-test and post-test counselling is conducted by the same counsellor.As a particularly valuable counselling tool,Christopher Knoll mentions the risk assessment questionnaire that is handed out prior toevery potential test, routinely asking aboutanal and oral sex practices.“The counsellor will then go over each question in the questionnaire together with the client, thereby creating a solid foundation forcounselling.” This makes it easier to incorporate taboo subjects into the counselling sessions.“I often see how much people welcome achance to talk about sexuality in a counsellingsession”, confirmsRegina Mosdzen. “Fixpunkt” is now frequented not only by drug users, but also by gaymen and many others who appreciate the fa9
HIVreport 1/2012: Rapid TestsThe medical department of Deutsche AIDSHilfe regularly offers training programmes fortesting project staff and has defined qualitystandards for proper testing procedures in therecently update brochure “HIV and STI Tests:Information and Standards 2012/2013”.This makes counselling more in-depth”, explains Lemmen, summarising the benefits oftheir service. “For the time being, rapid testing is a wonderful addition to HIV prevention.Things may be different five years from now.This is why DAH supports testing projectsand collects their experiences to stay on topof new developments.”Steffen TaubertAn alternative to rapid tests: Community-based counselling and testing services by Hein & Fiete in HamburgSadlowski, N., Drewes, J. & Kleiber, D. (2011):Aufsuchende HIV-Test- und Beratungsangebote fürMSM in Deutschland. Ergebnisse einer qualitativenExpertenbefragung (Schriftenreihe des Instituts fürPrävention und psychosoziale GesundheitsforschungNr. 05/P11). Berlin: Freie Universität Berlin. Der Berichtsteht als kostenloser Download zur Verfügung: www.fuberlin.de/ppg - Publikationen - ForschungsberichteReferencesBremer V, Brockmeyer N, Hagedorn H-J, Marcus U,Meyer T, Nitschke H, Nick S, Ross S, Straube E(2012): Schnelltests in der Diagnostik sexuellübertragbarer Infektionen; Gemeinsame Stellungnahmedes RKI, PEI und der DSTIG. EpidemiologischesBulletin des RKI, 06.02.2012 (Nr. 5).Schmidt AJ: Alles auf GUM; Warum wir in EuropasMetropolen Zentren für schwule Gesundheit brauchen.Vortrag auf dem Deutsch-Österreichischen AIDSKongress, Hannover, Juni 2011.Deutsche AIDS-Hilfe 2012: HIV- und STI-Tests: Informationen und Standards 2012/2013. 3. Auflage, Bestellnummer 116001, als PDF online.Drewes J, Kraschl C, Kleiber D (2011): Evaluation derKampagne „Ich weiß was ich tu“. Endbericht. 31. März2011. FU Berlin. www.fu-berlin.de/ppgSiedner et al. (2004): Performance of rapid syphilis testin venous and fingerstick whole blood specimens. SexTransm Dis 31: 557–560.Hagedorn H-J, Kraminer-Hagedorn A, MünstermannD (2012): Syphilis-Schnelltest; Präsentation von Dr. Dr.D. Münstermann am 04.02.2012 im Robert-KochInstitut in Berlin.The EMIS Network (2011): Community Report No2. ng et al. (2006): A mulit-center evaluation of ninerapid, point-of-care syphilis tests using archived sera.Sex Transm Inf 82, Suppl V: v7–v12.Zoufaly A, an der Heiden M, Marcus U, Hoffmann C,Stellbrink HJ, Voss L, van Lunzen J, Hamouda O,the ClinSurv Study Group (2012): Late presentationfor HIV diagnosis and care in Germany. HIV Medicine,13:172–181. doi:10.1111/j.1468-1293.2011.00958.x.Li J, Zheng HY et al. (2009): Clinical evaluation of fourrecombinant Treponema pallidum antigen-based rapiddiagnostic tests for syphilis. J Eur Acad DermatolVenereol 23: 648–650.Marcus U: Wer sucht, der findet. Prävalenz pharyngealer und rektaler Infektionen bei MSM. Vortrag auf demDeutschen STD-Kongress, Frankfurt am Main, September 2011Pai NP, Balram B, Shivkumar S, Martinez-Cajas JL,Claessens C, Lambert G, Peeling RW, Joseph L(2012): Head-to-head comparison of accuracy of arapid point-of-care HIV test with oral versus wholeblood specimens: a systematic review and metaanalysis.10 p
Pros and cons of rapid tests . Not all testing projects of AIDS service organ-isations use rapid tests: The pros and cons basically balance each other out. Whether or not rapid tests can be usedpurposeful ly ulti-mately depends on the local circumstances and the judgement of the responsible physi-cian. Pros
Artificial intelligence: opportunities and implications for the future of decision making. 9 November 2016. Big data, artificial intelligence, machine learning and data protection 20170904 Version: 2.2 7 This may not sound very different from standard methods of data analysis. But the difference is that AI programs don’t linearly analyse data in the way they were originally programmed .
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this blueprint paves the way for change for the children’s social care system, acknowledging the complexity and inherently risky nature of the work. While questions on how this will work in practice will need to be decided by individual LAs, this blueprint provides a starting point. Signifi cant benefi ts can be gained through LAs and the profession generally embracing the proposed model .
CREATING THE BLUEPRINT FOR YOUR “HOUSE” Cynthia Grant, PhD University of Colorado-Denver Azadeh Osanloo, PhD New Mexico State University The theoretical framework is one of the most important aspects in the research process, yet is often misunderstood by doctoral candidates as they prepare their dissertation research study. The importance of theory-driven thinking and acting is emphasized .
Jacqui True is Lecturer in International Politics, University of Auckland, New Zealand. x. Chapter 1 Introduction SCOTT BURCHILL AND ANDREW LINKLATER Frameworks of analysis The study of international relations began as a theoretical discipline. Two of the foundational texts in the field, E. H. Carr’s, The Twenty Years’ Crisis (first published in 1939) and Hans Morgenthau’s Politics Among .
How to use Cambridge Global English 7 How to use Cambridge Global English A Components Cambridge Global English offers the following components: The Learner’s Book provides the core input of the course and consists of nine thematic units of study. Each unit contains six lessons developed around a unifying theme, and linked to a main question at the beginning of the unit. The materials .
the expected effects of climate change on water resources and water programs. This knowledge will help us to prepare for and adapt to the effects of climate change. The information in this module is organized by the following questions: 1. Climate Change 101: How is the global climate changing and what are the causes?
