An Analysis of User Survey Data for an Internet Program for Testing for Sexually Transmitted Infections, I Want the Kit, in Maryland and Washington, DC

A Perspective on Home-Based Sexual Health Care: Evidence, Access, and Future Directions

PURPOSE

This perspective explores the impact of home-based sexual health services on accessibility to STI and HIV testing for priority populations. This study evaluates home-based services as independent care options and as complementary components of traditional clinic-based care.

RECENT FINDINGS

Challenges for persons to attend clinic-based sexual health care can be overcome by offering lower threshold home-based sexual health care. Implementing home-based services has successfully reached priority populations, including previously untested men who have sex with men (MSM) and individuals with a high exposure risk for sexually transmitted infections (STI) including human immunodeficiency virus (HIV), attending location-based sexual health care. A challenge in home-based services is to ensure equitable care, such as for individuals with limited access to digital resources or low health literacy. While home-based sexual health services enhance the accessibility of sexual healthcare, to ensure equitable care, research into the needs of still underserved populations and subsequent tailoring of the care offered, is needed. Continuous monitoring and evaluation of the implementation of home-based services may maximize the advantages of this promising type of care.

How does online postal self-sampling (OPSS) shape access to testing for sexually transmitted infections (STIs)? A qualitative study of service users

BACKGROUND

Sexually transmitted infections (STIs) are a serious public health issue in many countries. Online postal self-sampling (OPSS) is increasingly used to test for STIs, a trend accelerated by the COVID-19 pandemic. There remains limited understanding of how service users experience OPSS and what leads them to access it over clinic-based services, or vice versa. This research seeks to address these gaps, by undertaking a large qualitative study which sits within the ASSIST study, a mixed-methods, realist evaluation of OPSS.

METHODS

Participants were recruited via clinic-based and online sexual health services in three case study areas in England. Purposive sampling was used to over-represent populations disproportionately affected by poor sexual health: young people; people of colour; men who have sex with men; and trans and non-binary people. Semi-structured interviews were analysed using Levesque's conceptual framework of access to healthcare.

RESULTS

We interviewed 100 service users. Participants typically became aware of OPSS from sexual health services, the internet or word of mouth. Acceptability of OPSS was facilitated by the perceived privacy it offered over clinic-based services, which some participants found embarrassing to access. OPSS also enabled participants to overcome barriers to reaching clinic-based services, such as a lack of appointment availability, although difficulty obtaining OPSS kits in some areas undermined this. As all services in our case study areas were free to use, affordability did not significantly shape access, although OPSS enabled some participants to avoid costs associated with travelling to clinic-based services. Participants were usually able to engage with OPSS, finding it easy to use and reliable, although blood self-sampling was challenging for most. Participants valued the support offered by clinic-based services beyond STI testing, including the opportunity to access contraception or ask staff questions, and felt this was more appropriate when they had specific concerns about their sexual health, such as STI symptoms.

CONCLUSIONS

Our findings constitute one of the largest qualitative studies to have explored OPSS and offer valuable insights to providers. OPSS shapes access to STI testing in a number of ways, including facilitating access in many circumstances, but users also want to retain access to clinic-based services, particularly for when they believe they need support beyond STI testing.

Service user experiences of using internet-based testing for sexually transmitted infections (STIs): a qualitative study

OBJECTIVES

Internet-based testing for sexually transmitted infections allows individuals to order a self-sampling kit online, send samples to a central laboratory and receive their results electronically, reducing the need to attend a clinic unless for treatment. Its usage has grown rapidly in many high-income countries, such as England, where it now accounts for 44% of tests within the National Chlamydia Screening Programme. However, there is limited data on the experiences of service users, which may offer insights into low uptake and poor return rates among some high-incidence populations.

METHODS

Participants were recruited via sexual health clinics and the website of an internet-based testing service. Purposive sampling was used to ensure a diversity of genders, sexualities and ethnic backgrounds were included. Semistructured interviews were conducted by phone, email and messenger services and explored participants' perceptions and experiences of both internet-based and clinic-based testing. Data underwent thematic analysis.

RESULTS

We interviewed 17 participants. Internet-based testing appealed to many due to the privacy and convenience it offered over clinic-based testing. Although most were positive about their experience of internet-based testing, many found the process of finger-prick blood sampling extremely challenging and this contributed to concerns from some participants that test results may be inaccurate. A minority of participants missed the opportunity that clinic-based testing offered to discuss symptoms or concerns with staff. Participants overwhelmingly found the process of receiving test results by short message service (SMS) acceptable and preferable to alternatives.

CONCLUSIONS

Internet-based testing is viewed positively by most users but uptake may be improved if providers emphasise the privacy and convenience it offers, as well as the accuracy of self-sampling. Providers should also consider measures to address user concerns around blood sampling and access to specialist advice.

Evaluation of self-directed specimen collection for chlamydia and gonorrhea testing among people who use drugs

Background: People who use drugs (PWUD) often have elevated sexually transmitted infection (STI) risk and unmet healthcare needs. Self-directed STI specimen collection (i.e., individuals collect the specimen and mail to the laboratory) may be valuable in addressing STI testing barriers among PWUD. Methods: Within a cohort study among PWUD in New York City, we conducted a cross-sectional substudy from November 2021-August 2022 assessing sexual health with a one-time online survey (n = 120); participants could opt-in to receive a self-collection kit. Participants who opted-in were mailed a kit containing collection materials (males: urine cup, females: vaginal swab), pre-paid return label, instructions, and educational information. Specimens were sent to the laboratory and tested for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). We measured the number of kits requested, delivered, mailed to the lab, and CT/GC positive; and examined differences in requesting a kit by sociodemographic and behavioral characteristics. Results: Sixty-three total kits were requested by 44 unique participants. Of the 63 requested, 41 were delivered; one kit was undeliverable at the provided address and the rest were not sent due to no address provided or being duplicate requests. Of the 41 kits delivered, three participants returned the kit to the lab; of those, one was positive for CT and GC. The greatest differences in those who did and did not request a kit were observed by age, sexual orientation, past-year sex trade and casual partnerships, and experiences of relationship violence. Conclusions: Self-directed specimen collection may be desirable for PWUD, but research is needed to understand barriers to this testing approach for this population.

The impact of COVID-19 pandemic on technologic and process innovation in point-of-care diagnostics for sexually transmitted infections

The STI diagnostic landscape of FDA cleared tests for use at point-of-care (POC), as well as those emergency use authorized for COVID-19 are reviewed; some of these COVID-19 diagnostics may have platform potential as STI diagnostics. Finally, process innovation is described with self-collection and hub-and-spoke mail-in to reference lab models. Movement of Clinical Laboratory Improvement Amendments (CLIA)-waived POC tests to over-the-counter formats will make tests more accessible to consumers. Together with public health messaging, these measures could accelerate STI and COVID-19 syndemic diagnostic solutions.

Evaluation of a Statewide Online, At-Home Sexually Transmitted Infection and Human Immunodeficiency Virus Screening Program

BACKGROUND

Innovative approaches such as online, at-home programs may address important barriers to sexually transmitted infection (STI) and human immunodeficiency virus (HIV) screening in the United States. This study evaluated the first year of an online, at-home program offering HIV and triple-site (urogenital, rectal, and pharyngeal) gonorrhea (GC) and chlamydia (CT) testing in Colorado.

METHODS

Test Yourself Colorado (TYC) is an online, at-home program that provides free mailed HIV tests and/or GC/CT tests to Colorado adults. Program use and outcomes between 1 June 2021 and 31 May 2022 were analyzed.

RESULTS

A total of 1790 unique clients utilized TYC. Of 1709 clients who ordered HIV tests, 508 (29.7%) were men who have sex with men (MSM), and 41.3% (210/508) of these clients reported having never been tested for HIV before or were not tested in the prior year. Hispanic clients had lower STI test return rates (37.1%; 134/361) compared with non-Hispanic clients (45.9%; 518/1128) (P = .003). Positive STI tests were identified in 9.6% (68/708) of clients. Positive STI tests were more common in MSM clients (15.7%; 34/216) compared with all other sexual orientations (6.9%; 34/492) (P < .001). STI treatment was confirmed in 80.9% (55/68) of clients.

CONCLUSIONS

The TYC online, home testing portal is a scalable tool that reaches clients at risk of STIs and HIV and navigates those with positive STI tests to treatment. HIV/STI home testing programs need to further assess and address utilization and outcomes for disparities by race and ethnicity to assure programs equitably benefit all at-risk communities.

Advances in Sexually Transmitted Infection Testing at Home and in Nonclinical Settings Close to the Home

A commentary on recent successes and challenges for home STI specimen collection, for point-of-care test usage close to the home, and implications of COVID-19 self-tests for future STI self-test development.

Impact of the COVID-19 Pandemic on Chlamydia and Gonorrhea Tests Performed by a Large National Laboratory-United States, 2019 to 2020

BACKGROUND

During the COVID-19 pandemic, disruptions were anticipated in the US health care system for routine preventive and other nonemergency care, including sexually transmitted infection care.

METHODS

Using a large national laboratory data set, we assessed the impact of the COVID-19 pandemic on the weekly numbers and percent positivity of chlamydia and gonorrhea tests ordered from the 5th week of 2019 to the 52nd week of 2020 in the United States. We compared weekly 2020 values for test volume, percent positive, and number of positives with the same week in 2019. We also examined the potential impact of stay-at-home orders for the month of April 2020.

RESULTS

Immediately after the declaration of a national emergency for COVID-19 (week 11, 2020), the weekly number of gonorrhea and chlamydia tests steeply decreased. Tests then rebounded toward the 2019 pre-COVID-19 level beginning the 15th week of 2020. The weekly percent positive of chlamydia and gonorrhea remained consistently higher in 2020. In April 2020, the overall number of chlamydia tests was reduced by 53.0% (54.1% in states with stay-at-home orders vs. 45.5% in states without stay-at-home orders), whereas the percent positive of chlamydia and gonorrhea tests increased by 23.5% and 79.1%, respectively.

CONCLUSIONS

To limit the impact of the pandemic on control of chlamydia and gonorrhea, public health officials and health care providers can assess measures put in place during the pandemic and develop new interventions to enable care for sexually transmitted infections to be delivered under pandemic and other emergency conditions. The assessment like this study is continuously needed.

Factors Associated with Syphilis Transmission and Acquisition Among Men Who Have Sex with Men (MSM): Protocol for a Multi-Site Egocentric Network Study (Preprint)

BACKGROUND

In the United States, the rates of primary and secondary syphilis have increased more rapidly among men who have sex with men (MSM) than among any other subpopulation. Rising syphilis rates among MSM reflect changes in both individual behaviors and the role of sexual networks (eg, persons linked directly or indirectly by sexual contact) in the spread of the infection. Decades of research examined how sexual networks influence sexually transmitted infections (STIs) among MSM; however, few longitudinal data sources focusing on syphilis have collected network characteristics. The Centers for Disease Control and Prevention, in collaboration with 3 sites, enrolled a prospective cohort of MSM in 3 US cities to longitudinally study sexual behaviors and STIs, including HIV, for up to 24 months.

OBJECTIVE

The Network Epidemiology of Syphilis Transmission (NEST) study aimed to collect data on the factors related to syphilis transmission and acquisition among MSM.

METHODS

The NEST study was a prospective cohort study that enrolled 748 MSM in Baltimore, Maryland; Chicago, Illinois; and Columbus, Ohio. NEST recruitment used a combination of convenience sampling, venue-based recruitment, and respondent-driven sampling approaches. At quarterly visits, participants completed a behavioral questionnaire and were tested for syphilis, HIV, gonorrhea, and chlamydia. The participants also provided a list of their sexual partners and described their 3 most recent partners in greater detail.

RESULTS

The NEST participants were enrolled in the study from July 2018 to December 2021. At baseline, the mean age of the participants was 31.5 (SD 9.1) years. More than half (396/727. 54.5%) of the participants were non-Hispanic Black, 29.8% (217/727) were non-Hispanic White, and 8.8% (64/727) were Hispanic or Latino. Multiple recruitment strategies across the 3 study locations, including respondent-driven sampling, clinic referrals, flyers, and social media advertisements, strengthened NEST participation. Upon the completion of follow-up visits in March 2022, the mean number of visits per participant was 5.1 (SD 3.2; range 1-9) in Baltimore, 2.2 (SD 1.6; range 1-8) in Chicago, and 7.2 (SD 2.9; range 1-9) in Columbus. Using a community-based participatory research approach, site-specific staff were able to draw upon collaborations with local communities to address stigma concerning STIs, particularly syphilis, among potential NEST participants. Community-led efforts also provided a forum for staff to describe the NEST study objectives and plans for research dissemination to the target audience. Strategies to bolster data collection during the COVID-19 pandemic included telehealth visits (all sites) and adaptation to self-collection of STI specimens (Baltimore only).

CONCLUSIONS

Data from NEST will be used to address important questions regarding individual and partnership-based sexual risk behaviors among MSM, with the goal of informing interventions to prevent syphilis in high-burden areas.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/40095.

Contraception in Person-Contraception Online (CiP-CO) cohort study

BACKGROUND

Online contraception services increasingly provide information, clinical assessment and home-delivered oral contraceptives (OCs). Evidence is lacking on the effects of online contraceptive service use on short-term contraceptive continuation.

METHODS

Cohort study comparing contraceptive continuation between new users of a free-to-access online OC service in South East London with those from other, face-to-face services in the same area. Online questionnaires collected data on participants' sociodemographic characteristics, motivations for OC access, service ratings, OC knowledge and contraceptive use. Contraceptive use in the 4-month study period was measured using health service records. Unadjusted and multivariable logistic regression models compared outcomes between the online service group and those using other services.

RESULTS

Online service-users (n=138) were more likely to experience short-term continuation of OCs compared with participants using other services (n=98) after adjusting for sociodemographic and other characteristics (adjusted OR 2.94, 95% CI 1.52 to 5.70). Online service-users rated their service more highly (mean 25.22, SD 3.77) than the other services group (mean 22.70, SD 4.35; p<0.001), valuing convenience and speed of access. Among progestogen-only pill users, knowledge scores were higher for the online group (mean 4.83, SD 1.90) than the other services group (mean 3.87, SD 1.73; p=0.007). Among combined oral contraceptive users, knowledge scores were similar between groups.

CONCLUSIONS

Free-to-access, online contraception has the potential to improve short-term continuation of OCs. Further research using a larger study population and analysis of longer-term outcomes are required to understand the impact of online services on unintended pregnancy.

Diagnostic tests for detecting Chlamydia trachomatis and Neisseria gonorrhoeae in rectal and pharyngeal specimens

Chlamydia trachomatis and Neisseria gonorrhoeae are two of the most often reported bacterial infections in the United States. The rectum and oropharynx are important anatomic sites of infection and can contribute to ongoing transmission. Nucleic acid amplification tests (NAATs) are the mainstays for the detection of C. trachomatis and N. gonorrhoeae infections owing to their high sensitivity and specificity. Several NAATs have been evaluated for testing in rectal and pharyngeal infections. A few assays recently received clearance by the Food and Drug Administration, including one point-of-care test. Those assays can be used for testing in symptomatic individuals, as well as for asymptomatic screening in certain patient populations. Routine screening for C. trachomatis in pharyngeal specimens is not recommended by the Centers for Disease Control and Prevention, though is often performed due to the use of multiplex assays. While expanding the types of settings for screening and using self-collected rectal and pharyngeal specimens can help to increase access and uptake of testing, additional research is needed to determine the potential benefits and costs associated with increased screening for rectal and pharyngeal C. trachomatis and N. gonorrhoeae infections on a population level.

Sexually Transmitted Infection Testing Using Online Companies: Benefits, Drawbacks, and Call for Official Guidance

ABSTRACT

In this brief case series, we outline issues with some online sexually transmitted infection services and delayed reporting of results. Commercial entities providing sexually transmitted infection testing should ensure that all results are reported to local public health jurisdictions and that procedures exist to link persons to appropriate treatment and follow-up.

Scaling Up CareKit: Lessons Learned from Expansion of a Centralized Home HIV and Sexually Transmitted Infection Testing Program

BACKGROUND

Despite advances in implementing human immunodeficiency virus (HIV)/sexually transmitted infection (STI) services for men who have sex with men (MSM), many remain underserved because of barriers like stigma, low facility coverage, and provider competency. This article describes the implementation of centralized nationwide mailed HIV/STI home testing (CareKit).

METHODS

The Emory Center for AIDS Research developed CareKit for research study participants to request HIV self-test kits, STI specimen collection kits, and condom/lubricant packs to be shipped to any mailing address in the United States. Sexually transmitted infection kits were customized according to study needs and could include materials to collect whole blood, dried blood spots, urine sample, and rectal and pharyngeal swab samples for syphilis, gonorrhea, and chlamydia testing. Specimens were mailed back to a central Clinical Laboratory Improvement Amendments-approved laboratory for testing, and results were returned to participants.

RESULTS

CareKit was used by 12 MSM studies and mailed 1132 STI kits to 775 participants between January 2018 and March 2020. Participants returned 507 (45%) STI kits, which included 1594 individual specimens. Eighty-one kits (16%) had at least one positive STI test result: pharyngeal chlamydia (n = 7), pharyngeal gonorrhea (n = 11), rectal chlamydia (n = 15), rectal gonorrhea (n = 12), genital chlamydia (n = 6), genital gonorrhea (n = 1), and syphilis (n = 54). In this same 2-year period, 741 HIV self-test kits were mailed to 643 MSM.

CONCLUSIONS

CareKit successfully met studies' needs for home HIV/STI testing and diagnosed many STIs. These processes continue to be adapted for research and programs. The ability to mail home test kits has become increasingly important to reach those who may have limited access to health care services, particularly during the COVID-19 pandemic.

At-Home Testing for Sexually Transmitted Infections During the COVID-19 Pandemic

During the COVID-19 pandemic in New York City, NewYork-Presbyterian Hospital provided HIV prevention patients with gonorrhea/chlamydia testing kits at home. This report describes the program implementation to provide other sexual health clinics with a roadmap in adapting to a "new normal" in providing comprehensive sexual health care virtually to patients.

How do users of a 'digital-only' contraceptive service provide biometric measurements and what does this teach us about safe and effective online care? A qualitative interview study

OBJECTIVES

To describe user experience of obtaining and uploading biometric measurements to a 'digital-only' contraceptive service prior to a prescription for the combined oral contraceptive (COC). To analyse this experience to inform the design of safe and acceptable 'digital-only' online contraceptive services.

SETTING

An online contraceptive service available free of charge to women in South East London, UK.

PARTICIPANTS

Twenty participants who had ordered the combined oral contraceptive (COC) online. Our purposive sampling strategy ensured that we included participants from a wide range of ages and those who were and were not prescribed the COC.

INTERVENTION

A 'digital-only' contraceptive service that prescribes the COCafter an online medical history and self-reported height, weight and blood pressure (BP) with pills prescribed by a GMC registered doctor, dispensed by an online pharmacy and posted to the user.

DESIGN

Semistructured interviews with a purposive sample of 20 participants who were already enrolled in a larger study of this service.

ANALYSIS

Inductive, thematic analysis of the interviews assisted by NVivo qualitative analysis software.

RESULTS

Users valued the convenience of 'digital-only care' but experienced measuring BP but not height or weight as a significant barrier to service use. They actively engaged in work to understand and measure BP through a combination of recent/past measurements, borrowed machines, health service visits and online research. They negotiated tensions around maintaining a trusting relationship with the service, meeting its demands for accurate information while also obtaining the contraception that they needed.

CONCLUSION

Digital strategies to build trusting clinical relationships despite a lack of face-to-face contact are needed in 'digital-only' health services. This includes acknowledgement of work required, evidence of credible human support and a digital interface that communicates the health benefits of collaborating with an engaged clinical team.