 Hi, everyone. Thanks for that. So I'm going to be really talking about using the development of point of care tests for STIs and AMR as an example of the usefulness of social science alongside lab science for tech technology development and implementation. I can figure out how to progress my slides. There we go. So the four most common bacterial STIs are Pramedia, gonorrhea, trigoniasis, and mycoplasma genitalium. And you might have seen in the news over the past several years that a particular concern is drug resistant or super gonorrhea. But lesser known to organism mycoplasma genitalium is also a concern for antimicrobial resistance. The gold standard for bacterial STI detection is nucleic acid amplification tests, which are, which are necessitated by necessitate the large scale centralized laboratories. In the UK, we test for gonorrhea and chlamydia regularly using NACs, not so much for mycoplasma and trigoniasis in many low and middle income countries and indeed in some high income countries the facilities for NACs is limited because of the need for those large scale labs. But reliance on syndromic management. So the diagnosis of these infections by by looking at signs and symptoms and behavioral aspects is of risk is inadequate because these pathogens all have similar symptoms but require really different treatments. And as we've heard so far in the talks that incorrect suboptimal treatment has been shown to increase antimicrobial resistance and in STIs this is no less true. We've also heard earlier in Penn's talk the discussion around rapid diagnostics and particular point of care tests have potential to reduce antimicrobial resistance although there's some debate about about whether or not this this would work as a single use strategy. I'm going to go forward with the assumption that it will be helpful. So with all of that in mind, I developed a program of work that was funded by the NIHR and ran between 2014 and 2017 to help develop rapid point of care tests for STIs and antimicrobial resistance detection. And we were specifically looking at the potential for their use in specialist sexual health services here in the UK NHS. And so the issue was so I worked with a company called Bing's Health, and they were looking to develop a 30 minute point of care test. And they were looking to develop it for these four bacterial STIs but also for resistance detection for gonorrhea and mycoplasma. The problem was is that they couldn't put all of these detection assays onto one cartridge that would take 30 minutes. So with that in mind, what was the best way to configure these tests. And so my study spoke to clinicians in six different clinics, first to be able to understand what the current clinical pathways were for care and treatments. But then also to pose to them this question of which pathogens and which configurations of antimicrobial resistance detection would be best within their clinical setting. Once we got those pathways, I then posed those to patients within those six clinics and you can see on the map there, we did have some geographic variability and there was also variability with different types of clinics so some more traditional and others using new types of patient management systems. With that said, I'm going to present here just a very brief and simplified version of an existing clinical pathways, traditional pathway that you would see in many sexual health clinics here in the UK, where the patient comes in for a consultation, their sample is collected, that is then sent to the lab. The results would be sent from the lab to the clinic in about a week, and then the results would be forwarded from the clinic on to the patients. Within that process, what you see is that a subset of those will be treated presumptively. So with presumed infection, say if they have symptoms or they were sexual contact with somebody that had tested positive for specific infection. And then a subset would also be given microscopy so grams stay negative microscopy in clinic, but which is not a very sensitive test but quite a specific one. So, those that test positive by microscopy would also be given treatment clinic. So in this pathway the patient is released right after their consultation and their sample is collected and their microscopy results are ready if the clinic has microscopy facilities. So in this pathway you see a lot of overtreatment and especially along this line here on presumptive treatment. So when they asked clinicians what their considerations for these tests were, they said of course that the sensitivity and specificity or the accuracy should be comparable to the existing lab NACs that they use. And they felt that the multiplex test would be best at enabling better use of antibiotic so their preference was to have awkward pathogens on one cartridge with antimicrobial resistance testing on a separate cartridge. So they tried to drive down presumptive treatment, as well as drive down non specific diagnoses and increase treatment for specific infection so more accurate treatment decisions. They did advise caution that they said that they would need guidance from the professional organizations which here in the UK is the British Association for sexual health and HIV. They were to use these tests, and they especially had concerns around the epidemiology and emerging epidemiology around mycoplasma and trigonosis which are less known, because they're not tested for regularly here. And also an understanding that changing treatment would have population impacts and had concerns about that. There are lots of questions around patient acceptability of these new pathways, and specifically in this last one, whether or not they'd be willing to wait for results which is super important because of course the patient gets up and leaves before their results are ready it's no longer a point of care test. So how would they change these pathways. Well this is as if the current care pathway would be exactly the same except for you drop in the middle of point of care test rather than sending the sample to the lab. As you can see here the patient then sits is rerouted from the consultation and sits back in the waiting room for about a half an hour until the results are ready. If the patient was found to be positive, then they would have a reflex test along on a second cartridge for antimicrobial resistance detection, which would drive treatment decisions. Of course this requires quite a lot of waiting, especially for those positive patients so they also explored how this could potentially work in a little bit of a briefer way, and that was to have samples collected at triage. The patient was not waiting less necessarily but felt that they were waiting less because their result initial result would be ready right at the point of consultation. So what do patients think about this. I did that if they were concerned that they were infected they'd be quite happy to wait and click for their results as long as it took. So that it was really dependent on how they felt, and which is not always the same thing as whether or not they were the most clinically vulnerable for infection. So that's just something to keep in mind. And that's the only guidance on changes to these pathways and realistic estimates of waiting times, and that was so that they could plan their visits accordingly so they didn't think that they were going to just have a 1520 minute visit as was the norm previously. When we came to discussing about antimicrobial resistance things got a little bit more complicated. In some ways it was simple because they felt that their testing is tied to treatment delivery. So there's a high level of acceptability of waiting for results after receiving a positive infection result. So they would then spend that extra time to wait and be given their drugs before they left the clinic. So, in conclusion, how useful was this. Well, we found that they were very this was very useful and showing were important slides for clinicians and patients for a more detection capability for these tests, such as important benchmarks of a point of care test that should be passed, and how they could be used within different patient groups. They also were very useful with patients in terms of indicating when and why they felt that they would wait and how they, what was of importance to them particularly in that clinic process. They were less helpful for discussing and more generally as I said it became a little bit complicated because they really felt that decisions on treatment and when and where they received treatment was really going to be a medical decision made by a clinician, and that's something that they didn't have any control over. They had a lot of difficulty in answering questions on the importance of amr and specifically around what amr was was and how it could potentially impact their life and their treatment. Most said that they felt that amr was important, once it was explained to them that it could potentially be a resistant infection that they had, but, but there was a high level of potential acceptability bias as it was a very brief conversation and you would be likely to say that when somebody says that this is a global health problem. But this is one small topic and by this I mean antimicrobial resistance under a larger topic guide where we explored many different potential clinical pathways. So more focused discussion specifically on amr might have yielded different results. So what happened in the end, well with the company the technology design lock was before we received our final results, parking back to what sassy said in the very beginning that researchers are slow and technology development is fast. And this was driven by market concerns, but important to understand that most of these tests are developed in iterations. So this research has greatly informed the next generations of tests which are currently under development. And that's, that's all I have for you there. And I'm just going to leave you with a link to the, the published findings of the report. Thanks very much.