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

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.

Understanding Practical, Robust Implementation and Sustainability of Home-based Comprehensive Sexual Health Care: A Realist Review

This review identifies which elements of home-based comprehensive sexual health care (home-based CSH) impacted which key populations, under which circumstances. A realist review of studies focused on home-based CSH with at least self-sampling or self-testing HIV and additional sexual health care (e.g., treatment, counseling). Peer-reviewed quantitative and qualitative literature from PubMed, Embase, Cochrane Register of Controlled Trials, and PsycINFO published between February 2012 and February 2023 was examined. The PRISM framework was used to systematically assess the reach of key populations, effectiveness of the intervention, and effects on the adoption, implementation, and maintenance within routine sexual health care. Of 730 uniquely identified records, 93 were selected for extraction. Of these studies, 60% reported actual interventions and 40% described the acceptability and feasibility. Studies were mainly based in Europe or North America and were mostly targeted to MSM (59%; 55/93) (R). Overall, self-sampling or self-testing was highly acceptable across key populations. The effectiveness of most studies was (expected) increased HIV testing. Adoption of the home-based CSH was acceptable for care providers if linkage to care was available, even though a minority of studies reported adoption by care providers and implementation fidelity of the intervention. Most studies suggested maintenance of home-based CSH complementary to clinic-based care. Context and mechanisms were identified which may enhance implementation and maintenance of home-based CSH. When providing the individual with a choice of testing, clear instructions, and tailored dissemination successful uptake of STI and HIV testing may increase. For implementers perceived care and treatment benefits for clients may increase their willingness to implement home-based CSH. Therefore, home-based CSH may determine more accessible sexual health care and increased uptake of STI and HIV testing among key populations.

Undermining the Translational Potential of Clinical Research With Adolescents and Young Adults: Differential Enrollment in Randomized Clinical Trials During COVID-19

BACKGROUND

COVID-19 stay-at-home orders and research restrictions halted recruitment and follow-up of clinical research patients. Although clinical research has resumed, it is an open question whether research participation has returned to levels similar to those before COVID-19.

METHODS

We used data from the TECH-PN (NCT No. NCT03828994) study, a single-center randomized controlled trial enrolling 13- to 25-year-olds with mild-moderate pelvic inflammatory disease (PID) receiving ambulatory care. We examined enrollment patterns before COVID-19 and during/after COVID-19 among those assessed for eligibility by estimating the average rate of recruitment visits for each period. We focused on this monthly rate by pandemic status, the length of stay (LOS) by pandemic status, as well as the relationship between the LOS and patient demographics. Descriptive analyses were conducted, including Student t test to compare rates between time periods and a χ2 test to compare the proportion refusing enrollment.

RESULTS

The monthly enrollment rate during/after the pandemic was significantly lower than before COVID-19 (4.8 per month compared with 7.4 per month, P < 0.001). However, eligible participants' age, race, and insurance type were similar before and during/after the pandemic. Among eligible patients, LOS for receiving PID care was slightly increased, from a median of 5.4 to 6.4 hours ( P = 0.650), and the rate of refusal to participate among those eligible was similar (23% vs. 27%, P = 0.362). There were a similar number of ineligible patients because of inpatient admissions during both periods.

CONCLUSION

COVID-19 pandemic restrictions negatively impacted recruitment into this randomized controlled trial. Enrollment differences may reflect ongoing perceptions of restrictions in care access or a hesitancy to use health services. More research is needed to stabilize access to ambulatory sexually transmitted infection/PID care and access to clinical trials.

Trends in Patient's Use of Sexual Health Services During COVID-19 in a Network of STD Clinics, STD Surveillance Network, 2019 to 2021

BACKGROUND

The initial years of the COVID-19 pandemic disrupted sexual health care clinic's services. We describe use patterns by patient characteristics, and the use of telehealth (TH) services among a network of sexually transmitted disease (STD) clinics.

METHODS

Data were collected using a survey to assess the impact of COVID-19 from March to December 2020 among 7 jurisdictions who contribute STD visit-level data as part of the STD Surveillance Network. As a complement to the survey, retrospective data from January 2019 to December 2021 from these 7 STD clinics in the same 7 jurisdictions were examined for monthly utilization trends by overall visits, patient characteristics, and TH visits.

RESULTS

Survey results indicated 7 clinics prioritized patients for in-person visits and 4 jurisdictions reported urgent care centers were the most common referral location. In April 2020 (relative to April 2019) clinic visits and unique patients decreased by 68.0% and 75.8%, respectively. Telehealth were documented in 4 clinics, beginning in March 2020, peaking in December 2020, and tapering until December 2021. We observed the number of clinic visits (-12.2%) and unique patients presenting for care (-27.2%) in December 2021 had yet to return to levels to that seen in December 2019.

CONCLUSIONS

Sexually transmitted disease clinics showed fragility and resiliency in their adjustment to the pandemic; allowing for the continuation of services. Overall patient census has been slow to return to prepandemic levels, and many patients may still not be seeking timely care. This could result in missed opportunities to screen and treat STIs and increasing the possibility of harmful sequelae.

Evaluating the Impact of the COVID-19-Related Public Health Restrictions on Access to Digital Sexually Transmitted and Blood-Borne Infection Testing in British Columbia, Canada: An Interrupted Time Series Analysis

BACKGROUND

Evidence of long-term impacts of COVID-19-related public health restrictions on digital sexually transmitted and blood-borne infection (STBBI) testing utilization is limited. We assessed these impacts on GetCheckedOnline (a digital testing resource for STBBIs) relative to all STBBI tests in British Columbia (BC).

METHODS

Interrupted time series analyses were conducted using GetCheckedOnline program data comparing monthly test episodes (STBBI tests per requisition) among BC residents, stratified by BC region, and testers' sociodemographic and sexual risk profiles, for the prepandemic (March 2018-February 2020) and pandemic periods (March 2020-October 2021). Trends in GetCheckedOnline testing per 100 STBBI tests in BC regions with GetCheckedOnline were analyzed. Each outcome was modeled using segmented generalized least squared regression.

RESULTS

Overall, 17,215 and 22,646 test episodes were conducted in the prepandemic and pandemic periods. Monthly GetCheckedOnline test episodes reduced immediately after restrictions. By October 2021 (end of the pandemic period), monthly GetCheckedOnline testing increased by 21.24 test episodes per million BC residents (95% confidence interval, -11.88 to 54.84), and GetCheckedOnline tests per 100 tests in corresponding BC regions increased by 1.10 (95% confidence interval, 0.02 to 2.17) above baseline trends. After initial increases among users at higher STBBI risk (symptomatic testers/testers reporting sexual contacts with STBBIs), testing decreased below baseline trends later in the pandemic, whereas monthly GetCheckedOnline testing increased among people 40 years or older, men who have sex with men, racialized minorities, and first-time testers via GetCheckedOnline.

CONCLUSIONS

Sustained increases in utilization of digital STBBI testing during the pandemic suggest fundamental changes in STBBI testing in BC, highlighting the need for accessible and appropriate digital testing, especially for those most affected by STBBIs.

Qualitative Examination of the Impact of the COVID-19 Pandemic on Access and Adherence to Pre-exposure Prophylaxis (PrEP) Among Sexual and Gender Minorities

During the COVID-19 pandemic, pre-exposure prophylaxis (PrEP) access and adherence decreased nationwide. This study examined pandemic-related disruptions to PrEP access and adherence among clients of a health center (Center) in Los Angeles, California. Clients (n = 25) and Center personnel (n = 11) completed qualitative interviews from March to July 2021. Although the Center provided options for remote PrEP care (i.e., telehealth, STI self-testing kits, and prescription delivery), clients experienced difficulty navigating services or lacked equipment for telehealth. More than half (n = 13) of clients discontinued PrEP during COVID-19 due to decreased sexual partners, relocation, or insurance status changes. Among those who continued PrEP, the majority reported no change in adherence, while a minority reported worsening adherence due to distractions/forgetting, prescription refill issues, lack of insurance coverage, and fear of completing in-person visits. Findings highlight the challenges of navigating PrEP services during COVID-19 and suggest PrEP services enhancement to adapt to crisis events.

The impact of COVID-19 on the HIV continuum of care: challenges, innovations, and opportunities

INTRODUCTION

In February 2019, the United States (US) launched the Ending the HIV Epidemic (EHE) initiative with emphasis on improving the various steps of the Human Immunodeficiency Virus (HIV) prevention and care continuum. However, in March 2020, the Coronavirus Disease 2019 (COVID-19) pandemic was declared, curtailing efforts to end the epidemic in the US.

AREAS COVERED

To describe the impact of the pandemic on EHE in the US, the authors performed a comprehensive literature review focusing on outcomes at each step of the HIV care continuum. Simultaneously, they identified examples of pandemic-era innovations that may help EHE.

EXPERT OPINION

Numerous studies demonstrated pandemic-related disruptions across the care continuum as well as the impact on preexisting barriers to care among People with HIV (PWH) at higher risk for poor outcomes. As the pandemic progressed, innovative approaches to delivering healthcare and providing essential services emerged, including widespread use of telemedicine, expansion of home-based care, self-collected sexually transmitted infection (STI) and HIV testing, and co-located testing for COVID-19 and HIV/STIs. While the COVID-19 pandemic initially hindered achieving EHE in the US, the ability to be agile, flexible, and creative led to innovation in HIV care delivery that may ultimately assist in meeting EHE goals as we transition into the post-pandemic era.

Landscape Review of Mail-in Self-Collection, Programs for Sexually Transmitted Infections

BACKGROUND

Mail-in self-collection of samples with centralized reference laboratory sexually transmitted infection (STI) testing has been shown to be feasible with equivalent performance. Commercial, fee-for-service mail-in testing Web sites seem to be popular. These sites are currently unregulated by the US Food and Drug Administration.

METHODS

To compile a list of US organizations offering mail-in testing for STIs/HIV, the phrases "mail-in STI testing" and "home STI testing" were entered into search engines. Supplementary information was collected by organization email or "Contact Us" submission.

RESULTS

Information was collected from 20 programs in the United States offering STI mail-in, self-collection testing services. Five programs (25%) were free to consumers. Six organizations (30%) only offered prefixed kits (STIs tested could not be selected). Half of the organizations provided extragenital testing, 2 (10%) did not provide extragenital testing, and the 8 others (40%) did not clarify. Three organizations (15%) used their own laboratory, 11 (55%) did not provide laboratory information. One commercial laboratory provided services to 5 organizations.

CONCLUSIONS

Mail-in self-collection services are ubiquitous and exist in all states except 2; STI testing public health programs that offer testing at no cost to the consumer are only in 46% of states. Mail-in testing is likely a permanent fixture in sexual health services and will be an important component of a hybrid approach that complements that of static clinic services.

Point-of-Care Testing for Sexually Transmitted Infections

Point-of-care testing for sexually transmitted infections is essential for controlling transmission and preventing sequelae in high-risk populations. Since the World Health Organization published the ASSURED criteria, point-of-care testing has improved for use in large population screening and rapid testing that prevents loss of clinical follow-up. Recent advancements have been advantageous for low-resource areas allowing testing at a minimal cost without reliable electricity or refrigeration. Point-of-care nucleic acid detection and amplification techniques are recommended, but are often inaccessible in low-resource areas. Future advancements in point-of-care diagnostic testing should focus on improving antibody-based assays, monitoring viral loads, and detecting antimicrobial resistance.

[Sexually transmitted infections under the influence of the COVID-19 pandemic]

Sexually transmitted infections (STI) in Germany are constantly rising. STI screening and testing decreased during the coronavirus disease 2019 (COVID-19) pandemic due to redistribution of public health resources. During the pandemic, there was a decline in the diagnosis of STIs. A minor aspect of this could be explained by reductions in the number of sexual contacts and therefore actual reduced infections, but the greater aspect seems to be due to underdiagnosis. A dramatic surge of infections is expected in the next few years. It is of utmost importance to resume STI screening for early detection and treatment and thereby lowering the transmission of STIs.

"I Can't Take This Shitty Quarantine Anymore": Sexual Behavior and PrEP Use Among Young Men Who Have Sex with Men and Transgender Women in Brazil During the COVID-19 Pandemic

This study analyzes how the COVID-19 pandemic affected sexual behavior and use of HIV prevention methods among young transgender women (YTGW) and young gay, bisexual and other men who have sex with men (YGBMSM) participating in an HIV pre-exposure prophylaxis (PrEP) demonstration study in Brazil. Online interviews with 39 participants aged 15-22 years old were conducted between September and November 2020 and analyzed based on social constructionism and human rights-based approaches to health. The pandemic disrupted interviewees' routines, negatively affecting their life conditions. Among those who did not have a steady partner, social distance measures led to temporary interruption of sexual encounters and increased sexting and solo sex. Conversely, for those who had a steady relationship such measures contributed to increasing sexual practices and intimacy. Participants who had sexual encounters during the pandemic reported having continued to use PrEP. However, home confinement with family, lack of privacy, loss of daily routines and changes in housing impaired PrEP adherence and attendance at follow-up consultations. These results highlight the importance of maintaining HIV-service delivery for these groups during a public health crisis, as well as to address the structural drivers of the epidemic with comprehensive HIV prevention policies and by ensuring access of YGBMSM and YTGW to social protection policies.

Lifetime prevalence of syphilis infection among predominantly Black sexual and gender minorities living with HIV in Atlanta, Georgia: a cross-sectional analysis

OBJECTIVES

Syphilis infection disproportionately impacts Black sexual and gender minorities (SGM) in the United States. The extent of this impact among those living with HIV has been minimally examined. This study sought to examine lifetime syphilis prevalence and associated factors in a community sample of predominantly Black SGM living with HIV in the Southeastern US.

DESIGN

Participants (N = 174) enrolled in a stigma-mitigation trial for people living with HIV in Atlanta, Georgia, completed a sub-study involving testing for Treponema pallidum antibodies, indicative of lifetime syphilis infection. We performed chi-square and Fisher's exact tests to assess sociodemographic and healthcare differences by presence/absence of lifetime syphilis infection.

RESULTS

Most participants identified as non-Hispanic Black (n = 142/174; 81.6%) and cisgender male (n = 146/174; 83.9%). More than two thirds (n = 120/174) identified as gay/homosexual. We documented a 55.7% (n = 97/174) lifetime prevalence of syphilis infection and observed differences by sexual identity, with 77.3% (n = 75/97) of those screening positive reporting gay/homosexual identity relative to 58.4% (n = 45/77) of those screening negative (chi-square[1] = 7.8, p < 0.010).

CONCLUSION

Findings underscore how syphilis prevention efforts have missed the most marginalized, warranting a renewed, comprehensive strategy for improving the sexual health of Black SGM. Embedding targeted, respectful community engagement, expanded testing access, and healthcare provider training into broader sexual health and psychosocial wellness efforts is needed.

Providing HIV testing in men who have sex with men through a gay social networking app in China: A qualitative interview study with multisectoral service providers

Objective

We explored the feasibility of app-based HIV testing services (AHTS) among men who have sex with men (MSM) according to the perspectives of testing service providers.

Methods

Twenty-one current or previous AHTS providers participated in a semi-structured interview which explored the facilitators and barriers to AHTS. Ten participants originating from the Center for Disease Control and Prevention (CDC) and 11 from the non-governmental organization (NGO) in Shijiazhuang, China took part in this study. Interviews was transcribed verbatim, and the socioecological model (SEM) was applied to thematic analysis.

Results

Twenty-one participants from AHTS services commented on the integration of online appointment schedules into HIV testing services. AHTS was deemed a convenient and efficient method for MSM and service providers to choose their preferred location and times. Moreover, it allowed for important HIV-related information to be accessed online and targeted toward at-risk individuals. Participants thought MSM may feel unsure about personal information security being stored within a privatized app and was considered a barrier to AHTS's usability. As such, they believed establishing a government-led national online platform for AHTS would allow for greater trust from MSM, rather than a social media app.

Conclusion

By linking booking services to an online platform, AHTS was deemed a convenient and efficient method for HIV testing services, especially for young MSM who are familiar with smartphone applications. To improve the use of these services, AHTS apps should focus on ensuring the confidentiality of personal information and internet security to build trust between MSM and service providers.

Telehealth Services: Implications for Enhancing Sexually Transmitted Infection Prevention

ABSTRACT

In the United States, sexually transmitted infections (STIs) are among the most persistent threats to health equity. Increasing access to STI prevention and control services through the provision of Remote Health and Telehealth can improve sexual health outcomes. Telehealth has been shown to increase access to care and even improve health outcomes. The increased flexibility offered by Telehealth services accommodates both patient and provider. Although both Telehealth and Remote Health strategies are important for STI prevention, share common attributes, and, in some circumstances, overlap, this article will focus more specifically on considerations for Telehealth and how it can contribute to increasing health equity by offering an important complement to and, in some cases, substitute for in-person STI services for some populations. Telehealth assists a variety of different populations, including those experiencing STI disparities; however, although the Internet offers a promising resource for many American households and increasing percentages of Americans are using its many resources, not all persons have equal access to the Internet. In addition to tailoring STI programs to accommodate unique patient populations, these programs will likely be faced with adapting services to fit reimbursement and licensing regulations.

Intersecting epidemics: the impact of coronavirus disease 2019 on the HIV prevention and care continua in the United States

OBJECTIVE

To summarize the broad impact of the coronavirus disease 2019 (COVID-19) pandemic on HIV prevention and care in the United States with a focus on the status-neutral HIV care continuum.

DESIGN

We conducted an editorial review of peer-reviewed literature on the topics of HIV-risk behaviors, sexually transmitted illness (STI) and HIV prevalence, HIV prevention and treatment trends, and evolving practices during the COVID-19 pandemic.

METHODS

For relevant literature, we reviewed, summarized, and categorized into themes that span the HIV prevention and care continua, including sexual risk behaviors, mental health, and substance use.

RESULTS

We identified important changes within each component of the HIV care continuum across the United States during the COVID-19 pandemic. Shifts in prevention practices, engagement with care, care provision, medication adherence, testing, and prevalence rates were observed during the pandemic.

CONCLUSION

Although heightened disparities for people at risk for, and living with, HIV were seen during the COVID-19 pandemic, many health systems and clinics have achieved and maintained engagement in HIV prevention and care. This review highlights barriers and innovative solutions that can support durable and accessible health systems through future public health crises.

Factors Associated With New Sexual Partnerships During the COVID-19 Pandemic: A Survey of Online Sexually Transmitted Infection Testing Platform Users

BACKGROUND

The COVID-19 pandemic has coincided with an explosion of online platforms for sexually transmitted infections (STIs) testing using self-collected, mail-in specimens. Reports on the effect of COVID-19-associated restrictions on sexual behaviors have been mixed, but STI transmissions have continued during the pandemic. We sought to understand the pandemic impact on sexual habits associated with STIs among IWantTheKit users.

METHODS

Users of IWantTheKit, a free, online STI testing platform, were invited to complete an anonymous questionnaire. Descriptive statistics were used to describe survey responses. Associations with reports of new sex partnerships were explored as a marker of STI risk. Descriptive statistics, univariate and multivariate logistic regression models were used to analyze individual characteristics and reported behaviors associated with self-reported new sexual partnerships during the first 2 COVID-19 pandemic waves.

RESULTS

Of the 3462 users of the online STI testing platform between June 2020 and February 2021, 1088 (31.4%) completed the online survey; 705 (66.2%) of 1065 reported a new sex partner. One-quarter met their sex partners using apps. Overall, 10% were symptomatic and almost 18% were concerned that their partner had an STI. White race in men (odds ratio, 1.81; 95% confidence interval, 1.04-3.16), women younger than 25 years (odds ratio, 1.85; 95% confidence interval, 1.09-3.14), and increased condom use in both men and women were significantly associated with reports of new sexual partnerships in adjusted analysis.

CONCLUSIONS

Despite pandemic restrictions on social gatherings, new sexual partnerships were common in this population, associated with common risk factors, and may help to explain ongoing STI transmission.

Sexually Transmitted Infection Transmission Dynamics During the Coronavirus Disease 2019 (COVID-19) Pandemic Among Urban Gay, Bisexual, and Other Men Who Have Sex With Men

BACKGROUND

The impact of coronavirus disease 2019 (COVID-19) mitigation measures on sexually transmitted infection (STI) transmission and racial disparities remains unknown. Our objectives were to compare sex and drug risk behaviors, access to sexual health services, and STI positivity overall and by race during the COVID-19 pandemic compared with pre-pandemic among urban sexual minority men (MSM).

METHODS

Sexually active MSM aged 18-45 years were administered a behavioral survey and STI testing every 3-months. Participants who completed at least 1 during-pandemic (April 2020-December 2020) and 1 pre-pandemic study visit (before 13 March 2020) that occurred less than 6 months apart were included. Regression models were used to compare during- and pre-pandemic visit outcomes.

RESULTS

Overall, among 231 MSM, reports of more than 3 sex partners declined(pandemic-1: adjusted prevalence ratio 0.68; 95% confidence interval: .54-.86; pandemic-2: 0.65, .51-.84; pandemic-3: 0.57, .43-.75), substance use decreased (pandemic-1: 0.75, .61-.75; pandemic-2: 0.62, .50-.78; pandemic-3: 0.61, .47-.80), and human immunodeficiency virus/preexposure prophylaxis care engagement (pandemic-1: 1.20, 1.07-1.34; pandemic-2: 1.24, 1.11-1.39; pandemic-3: 1.30, 1.16-1.47) increased. STI testing decreased (pandemic-1: 0.68, .57-.81; pandemic-2: 0.78, .67-.92), then rebounded (pandemic-3: 1.01, .87-1.18). Nei-ther Chlamydia (pandemic-2: 1.62, .75-3.46; pandemic-3: 1.13, .24-1.27) nor gonorrhea (pandemic-2: 0.87, .46 1.62; pandemic-3: 0.56, .24-1.27) positivity significantly changed during vs pre-pandemic. Trends were mostly similar among Black vs. non-Black MSM.

CONCLUSIONS

We observed sustained decreases in STI risk behaviors but minimal change in STI positivity during compared with pre-pandemic. Our findings underscore the need for novel STI prevention strategies that can be delivered without in-person interactions.

Rapid Uptake of Testing for Chlamydia, Gonorrhea, and HIV From an Online Platform, April-October 2020

The Baltimore City Health Department (Baltimore, MD) promoted IWantTheKit for chlamydia, gonorrhea, and HIV testing to city residents and clinic patients when COVID-19 restricted in-person clinic services. From April to October 2020, monthly online IWantTheKit orders increased by 645%. A high prevalence of chlamydia and gonorrhea was detected, and 96% of users who tested positive for chlamydia and gonorrhea were successfully contacted for treatment. Uptake by Baltimore City Health Department priority populations and excellent treatment linkage demonstrated how a public health-academic partnership successfully addressed a service gap during the pandemic. (Am J Public Health. 2022;112(7):985-989. https://doi.org/10.2105/AJPH.2022.306835).

Human Immunodeficiency Virus/Sexually Transmitted Infection Testing Preferences for Young Black Men Who Have Sex With Men in the Southeastern United States: Implications for a Post-COVID-19 Era

BACKGROUND

Little is known regarding human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing preferences for location, staffing, and hours of operation among Young Black men who have sex with men (YBMSM) in the Southeastern United States, a population at high risk for HIV/STIs. We used a discrete choice experiment to explore these preferences.

METHODS

Young Black men who have sex with men ages 16 to 35 years in Birmingham, AL and Jackson, MS completed online surveys evaluating their preferences (best/worst) for HIV/STI testing locations, staffing, hours, method of results notification, and cost. They also selected preferred combinations of these variables through choice tasks. Results were analyzed using joint best/worst and discrete choice experiment models.

RESULTS

Between June 2018 and December 2019, participants in Alabama (n = 54) and Mississippi (n = 159) completed online surveys. Both groups preferred stationary testing locations over mobile testing vans, with the most significant difference favoring STI testing-only clinics in Mississippi and local health departments in Alabama (P < 0.001). Technician-performed tests or self-testing were significantly less preferred compared with clinician-performed testing for both groups (P < 0.0001 and P < 0.0001, respectively). Free testing and phone results notification (versus text) were preferred by both groups. The most desirable combination among all participants was weekday clinician-performed testing at the health department for $5.

CONCLUSIONS

Young Black men who have sex with men in the Southeastern United States prefer traditional testing locations staffed by experienced personnel. Combination choices are influenced by services that are low or no cost. More research is needed to inform the best way(s) to provide affordable, high-quality HIV/STI testing services for YBMSM, particularly in the post-COVID-19 era when sexual health care delivery models are evolving toward home-based and remote health-focused strategies.

If We Make It, Will They Take It? Attitudes Toward the Acceptability of Chlamydia Point-of-Care Testing Among Adolescents and Young Adults

BACKGROUND

Adolescent women, 15 to 19 years of age, have the highest rate of Chlamydia trachomatis infection in the United States. The objective of this study was to ascertain knowledge and experience of C. trachomatis and acceptance of C. trachomatis point-of-care testing (POCT) if made available over-the-counter (OTC). Currently, there are no tests for C. trachomatis available OTC for purchase.

METHODS

Patients attending adolescent clinics at University Hospital of Brooklyn and Kings County Hospital received an anonymous 12-item questionnaire. Both clinics serve predominantly African and Caribbean American urban populations. Questions included demographics, sexual orientation, chlamydia knowledge, testing history, prior infection, partner notification, and acceptance of OTC POCT for C. trachomatis.

RESULTS

Surveys from 151 patients (116 women, 35 men) aged 12 to 21 years (mean age, 17.6 years) were analyzed. Only 34 of the 151 (22.5%) respondents understood C. trachomatis transmission; 31 (20.5%) knew its complications. Sixty-seven (44.4%) would purchase an OTC test but 101 (66.8%) would pay no more than $20. All 151 patients reported that they would follow-up with doctor if positive; 143 (94.7%) would notify partners, although 5 of the 31 (16.1%) women with prior infection did not notify partners.

CONCLUSIONS

Nearly half (44%) of adolescents in our population would be interested in using a potential OTC test for C. trachomatis. Cost was a major disincentive. Knowledge of infection remains cursory. However, those with a history of C. trachomatis infection and familiar with its complications were more interested in purchasing a home test. Although 100% of the respondents reported that they would follow-up with their physician if they tested positive, past behavior suggests that partner notification might be suboptimal.

Adherence, Sexual Behavior and Sexually Transmitted Infections in a New Zealand Prospective PrEP Cohort: 12 Months Follow-up and Ethnic Disparities

Inequities in pre-exposure prophylaxis (PrEP) experiences will impede HIV epidemic elimination among gay and bisexual men (GBM). Ethnicity is a strong marker of inequity in the United States, but evidence from other countries is lacking. We investigated experiences on-PrEP to 12 months follow-up in a prospective cohort of 150 GBM in Auckland, New Zealand with an equity quota of 50% non-Europeans. Retention at 12 months was 85.9%, lower among Māori/Pacific (75.6%) than non-Māori/Pacific participants (90.1%). Missed pills increased over time and were higher among Māori/Pacific. PrEP breaks increased, by 12 months 35.7% of Māori/Pacific and 15.7% of non-Māori/Pacific participants had done so. Condomless receptive anal intercourse partners were stable over time. STIs were common but chlamydia declined; 12-month incidence was 8.7% for syphilis, 36.0% gonorrhoea, 46.0% chlamydia, 44.7% rectal STI, 64.0% any STI. Structural interventions and delivery innovations are needed to ensure ethnic minority GBM gain equal benefit from PrEP.

Clinical trial number ACTRN12616001387415.

How the Disruption in Sexually Transmitted Infection Care Due to the COVID-19 Pandemic Could Lead to Increased Sexually Transmitted Infection Transmission Among Men Who Have Sex With Men in The Netherlands: A Mathematical Modeling Study

BACKGROUND

During the COVID-19 pandemic, the disruption in care for sexually transmitted infections (STIs) and the social distancing measures have led to reductions in STI testing and sexual behavior. We assessed the impact of these COVID-19-related changes on transmission of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) among men who have sex with men (MSM) in The Netherlands.

METHODS

We developed a mathematical model for CT and NG transmission among MSM, accounting for COVID-19-related changes in sexual behavior and testing in 2020 to 2021. Changes in 2020 were estimated from data from the Dutch COVID-19, Sex, and Intimacy Survey among MSM and the National Database of STI Clinics. Because of the lack of data for 2021, we examined several scenarios covering a range of changes.

RESULTS

A reduction of 10% and 40% in STI testing of symptomatic and asymptomatic, respectively, individuals with a 10% to 20% reduction in numbers of casual partners (according to partner status and activity level) during the second lockdown, resulted in a 2.4% increase in CT prevalence, but a 2.8% decline in NG prevalence in 2021. A 5% and 30% reduction in STI testing of symptomatic and asymptomatic, respectively, individuals with the same reduction in casual partners resulted in a 0.6% increase in CT prevalence and a 4.9% decrease in NG prevalence in 2021.

CONCLUSIONS

The disruption in STI care due to COVID-19 might have resulted in a small increase in CT prevalence, but a decrease in NG prevalence. Scaling up STI care is imperative to prevent increases in STI transmission.

A randomized controlled trial of an mHealth intervention for increasing access to HIV testing and care among young cisgender men and transgender women: the mLab App study protocol

BACKGROUND

The number of youth living with HIV in the United States (US) continues to rise, and racial, ethnic, and sexual minority youth including young men who have sex with men (YMSM) and young transgender women (YTGW) bear a disproportionate burden of the HIV epidemic. Due to social and healthcare system factors, many YMSM and YTGW do not seek HIV testing services and are therefore less likely to be aware that they are infected. Mobile health technology (mHealth) has the ability to increase uptake of HIV testing among these populations. Thus, the mLab App-which combines HIV prevention information with a mobile phone imaging feature for interpreting at-home HIV test results-was developed to improve testing rates and linkage to care among Black, Latino, and other YMSM and YTGW living in New York City and Chicago and their surrounding areas.

METHODS

This study is a three-arm randomized controlled trial among YMSM and YTGW aged 18-29 years. Participants are randomized to either the mLab App intervention including HIV home test kits and standard of preventive care, standard of preventive care only, or HIV home test kits and standard of preventive care only.

DISCUSSION

mHealth technology used for HIV prevention is capable of delivering interventions in real-time, which creates an opportunity to remotely reach users across the country to strengthen their HIV care continuum engagement and treatment outcomes. Specifically during the COVID-19 pandemic, mHealth technology combined with at-home testing may prove to be essential in increasing HIV testing rates, especially among populations at high-risk or without regular access to HIV testing.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov ( NCT03803683 ) on January 14, 2019.

Impact of coronavirus disease (COVID-19) on HIV testing and care provision across four continents

OBJECTIVES

The coronavirus disease (COVID-19) pandemic has been associated with severe disruptions in health care services, and nonpharmacological measures such as social distancing also have an impact on access to screening tests and on the long-term care of patients with chronic conditions globally. We aimed to describe the impact of the COVID-19 pandemic on HIV testing and treatment and to describe strategies employed to mitigate the impact of COVID-19 on HIV care.

METHODS

In this retrospective cohort study, we used secondary data from the AIDS Healthcare Foundation (AHF) Global Quality Program from 44 countries in four continents (Asia, Latin America and the Caribbean, Europe and Africa), and compared information on HIV testing, percentage of positive results, number of in-person appointments, and number of new enrolments in HIV care from 1 January 2020 to 31 August 2020 with the equivalent period in 2019.

RESULTS

Despite marked inter-country heterogeneities, we found that COVID-19 was associated with a significant reduction in HIV testing, an increase in the percentage of positive tests, a reduction in the number of in-person consultations and a reduction in the number of new enrolments in care, despite the implementation of several mitigation strategies. The impact of COVID-19 differed across continents and key populations.

CONCLUSIONS

Our findings suggest that, in the years to come, health care services must be prepared to respond to the impact of COVID-19 on HIV testing and care. Providers and facilities should build on the lessons learned so far to further improve mitigation strategies and establish care priorities for both the pandemic and the post-pandemic periods.

A Systematic Review of the Social Network Strategy to Optimize HIV Testing in Key Populations to End the Epidemic in the United States

The United States (U.S.) has a plan to end the HIV epidemic by 2030. The plan’s first pillar prioritizes HIV testing. Social Network Strategy (SNS) is an intervention to reach persons not routinely testing for HIV. We conducted a systematic review of SNS to understand its implementation to optimize HIV testing in the U.S. among key populations. The eligibility criteria included peer-reviewed papers based in the U.S. and focused on HIV testing. We identified and thematically analyzed 14 articles to explore factors associated with successful implementation. Key themes included: (1) social network and recruiter characteristics; (2) strategies for and effectiveness of recruiting key populations; (3) use of and types of incentives; (4) trust, confidentiality, and stigma concerns; and (5) implementation plans and real-world guidance. Cohort studies indicated that SNS detects more incident HIV cases. Partnerships with health departments are critical to confirm new diagnoses, as are developing plans that support recruiters and staff. SNS is a promising strategy to optimize HIV testing among key populations.

Decreases in Reported Sexually Transmitted Infections During the Time of COVID-19 in King County, WA: Decreased Transmission or Screening?

BACKGROUND

In response to the COVID-19 pandemic, Washington State's Stay Home, Stay Healthy (SHSH) order was implemented on March 24, 2020. We hypothesized that pandemic mitigation measures might reduce sexually transmitted infection (STI) screening and/or transmission.

METHODS

We used King County, WA STI surveillance and sexual health clinic (SHC) data from January 1, 2019, to July 31, 2020. We calculated mean weekly case counts for gonorrhea, primary and secondary (P&S) syphilis, male urethral gonorrhea, and early latent (EL) syphilis for 3 periods in 2020: pre-SHSH (January 1-March 23), SHSH (March 24-June 5), and reopening (June 6-July 31). Primary and secondary syphilis and male urethral gonorrhea were used as proxies for sexual behavior, and EL syphilis was used as a proxy for STI screening. We compared SHC visits (2019 vs. 2020) and SHC gonorrhea treatment practices (across 2020 periods).

RESULTS

Compared with January to July 2019, from January to July 2020, reported cases of gonorrhea, male urethral gonorrhea, P&S syphilis, and EL syphilis decreased by 9%, 5%, 16%, and 22%, respectively. Mean weekly case counts of gonorrhea, male urethral gonorrhea, and EL syphilis decreased pre-SHSH to SHSH, but all returned to pre-SHSH levels during reopening. Sexual health clinic visits during SHSH were 55% lower in 2020 than in 2019. In the SHC during SHSH, ceftriaxone treatment of gonorrhea decreased, whereas cefixime/cefpodoxime treatment and gonorrhea treatment with no testing increased.

CONCLUSIONS

Decreases in reported STIs concurrent with COVID-19 SHSH may reflect a true decline in STI transmission. However, the larger decreases in asymptomatic infections indicate that much of the observed decrease was likely due to decreased screening.

At-home Specimen Self-Collection and Self-Testing for STI Screening Demand Accelerated by the COVID-19 Pandemic - A Review of Laboratory Implementation Issues

The idea of specimen self-collection or self-STI testing is not new. In 2019, the World Health Organization (WHO) published the "WHO Consolidated Guideline on Self-Care Interventions for Health" as a first installment in a planned series for various diseases (8). The first document focused on "Sexual and Reproductive Health and Rights". Self-care including self-testing has the readily apparent benefits of privacy, confidentiality, speed, convenience, and access if the price is affordable. It is "people-centered" (9) and enables active participation in one's own health. It is also a health system approach as it can reduce burden on stretched systems with world-wide shortages in medical personnel or other barriers to health care access. Potential risks include: low specimen return rates, uncertain follow-up (linkage to care including treatment, repeat testing including test of cure, partner notification, counseling on risk reduction), unintended/unnecessary use (resulting in false positives with their own set of associated problems), incorrect use, lack of understanding of window periods (resulting in false negatives), lack of surveillance data generation, among other issues (9). The WHO systematically reviewed evidence for self-testing or specimen self-collection for GC, CT and syphilis, including US studies, and published a meta-analysis of available evidence (9). Programs offering self-collection of samples increased overall uptake of STI testing services (RR: 2.941, 95% CI 1.188 to 7.281) and case finding (RR: 2.166, 95% CI1.043 to 4.498), prior to the pandemic (9). U. S. laboratory research on the equivalence and/or superiority of self-collected versus provider-collected specimens for test sensitivity was reported by Gaydos et al (summarized or referenced in (10)). Based on this evidence, WHO issued a new recommendation in 2019 "Self-collection of samples for Neisseria gonorrhoeae and Chlamydia trachomatis should be made available as an additional approach to deliver STI testing services for individuals using STI testing services" (8). In addition, WHO issued a new and conditional recommendation: "Self-collection of samples for Treponema pallidum (syphilis) and Trichomonas vaginalis may be considered as an additional approach to deliver STI testing services for Individuals using STI testing services" (8). Thus, even before the COVID-19 pandemic, substantial expert agreement existed concerning benefits of this approach.