Assessing association between IWantTheKit risk quiz tool and sexually transmitted infection positivity in male users for sexually transmitted infection screening

Added Value of Extragenital Sexually Transmitted Infection Testing in "IWantTheKit" Program Users

BACKGROUND

The 2021 Centers for Disease Control and Prevention sexually transmitted infection treatment guidelines recommend extragenital testing for gonorrhea and chlamydia in men who have sex with men and for women based on reported behaviors and exposures. The "IWantTheKit (IWTK)" program is a free online platform for specimen self-collection and mail-in for combined chlamydia/gonorrhea testing. We sought to assess the additional diagnostic value of extragenital testing compared with genital testing only for chlamydia/gonorrhea and determine factors associated with a positive extragenital test result among IWTK users.

METHODS

From August 2013 to January 2022, 7612 unique IWTK users returned swabs for testing; 3407 (45%) users requested both genital and extragenital tests and were included in this analysis. Descriptive statistics were summarized for demographic characteristics, reported behaviors, and genital and extragenital test results, and data were stratified by gender and age group. A logistic regression model was used to estimate associations between factors and extragenital sexually transmitted infection positivity.

RESULTS

Chlamydia positivity rates were 4.7%, 2.4%, and 1.5% at genital, extragenital, and both sites, respectively; for gonorrhea, 0.4%, 1.1%, and 0.4% were positive at those sites, respectively. Among women, age 25 years and younger was significantly associated with extragenital chlamydia (odds ratio [OR], 4.0; P = 0.010). Being in high-risk quiz score group was associated with extragenital chlamydia (OR, 2.6; P = 0.005) and extragenital gonorrhea in men and women (OR, 8.5; P = 0.005).

CONCLUSIONS

Extragenital testing detected additional chlamydia and gonorrhea cases in the IWTK user population that would have been missed by genital-only testing, especially for women younger than 25 years and people reported to be at high risk.

Risk Prediction Score for Screening Asymptomatic Sexually Transmitted Infections in HIV-positive French Men Who Have Sex with Men (ANRS 9520 DRIVER)

OBJECTIVES

Asymptomatic sexually transmitted infections (STI) are frequent among men who have sex with men (MSM). Identifying asymptomatic STIs is a crucial issue, not only for secondary but also for primary prevention, as early treatment can reduce transmission risk. We aimed to develop a self-reported predictive score for early identification of asymptomatic STIs.

METHODS

Participants provided clinical data and completed a self-administered questionnaire including sociodemographic variables and behaviors during the 6 previous months. We used multivariable logistic regression to identify factors associated with asymptomatic STIs. We calculated the accuracy of the model by the non-parametric area (AUC) under the receiver-operating-characteristic (ROC) curve to find the optimal discriminant threshold for screening.

RESULTS

A total of 781 HIV-positive MSM were included with a mean age of 46.8 years. Asymptomatic STI prevalence was 13.2%. Detectable plasma HIV RNA (adjusted odds ratio (aOR [95% CI): 2.54 [1.23;5.25]), inconsistent condom use during anal sex (2.20 [1.36;3.56]), group sex (2.00 [1.15;3.45]), during or-genital practices (1.83 [1.12;3.01]), not being in stable relationship (1.70 [1.01;2.66] and an item from a sensation-seeking behavioral scale "I don't like watching porn videos" (1.61 [1.01;2.59] were associated with asymptomatic STI. AUC was 0.7 and with optimal threshold of 0.1082 for this model; sensitivity was 80.4%. Self-reported asymptomatic STI predictive score was built with this threshold according to the 6 factors in the final model.

CONCLUSIONS

As this predictive score is not designed to be diagnostic, but to provide indications for diagnostic tests, its ease of administration and sensitivity remain the most important features. Its use in clinical practice for early detection of asymptomatic STIs potentially can reinforce STI primary and secondary prevention.

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.

Validation of a Clinical Prediction Rule to Predict Asymptomatic Chlamydia and Gonorrhea Infections Among Internet-Based Testers

BACKGROUND

Clinical prediction rules (CPRs) can be used in sexually transmitted infection (STI) testing environments to prioritize individuals at the highest risk of infection and optimize resource allocation. We previously derived a CPR to predict asymptomatic chlamydia and/or gonorrhea (CT/NG) infection among women and heterosexual men at in-person STI clinics based on 5 predictors. Population differences between clinic-based and Internet-based testers may limit the tool's application across settings. The primary objective of this study was to assess the validity, sensitivity, and overall performance of this CPR within an Internet-based testing environment (GetCheckedOnline.com).

METHODS

We analyzed GetCheckedOnline online risk assessment and laboratory data from October 2015 to June 2019. We compared the STI clinic population used for CPR derivation (data previously published) and the GetCheckedOnline validation population using χ2 tests. Calibration and discrimination were assessed using the Hosmer-Lemeshow goodness-of-fit test and the area under the receiver operating curve, respectively. Sensitivity and the fraction of total screening tests offered were quantified for CPR-predicted risk scores.

RESULTS

Asymptomatic CT/NG infection prevalence in the GetCheckedOnline population (n = 5478) was higher than in the STI clinic population (n = 10,437; 2.4% vs. 1.8%, P = 0.007). When applied to GetCheckedOnline, the CPR had reasonable calibration (Hosmer-Lemeshow, P = 0.90) and discrimination (area under the receiver operating characteristic, 0.64). By screening only individuals with total risk scores ≥4, we would detect 97% of infections and reduce screening by 14%.

CONCLUSIONS

The application of an existing CPR to detect asymptomatic CT/NG infection is valid within an Internet-based STI testing environment. Clinical prediction rules applied online can reduce unnecessary STI testing and optimize resource allocation within publicly funded health systems.

Detection of Three Sexually Transmitted Infections by Anatomic Site: Evidence From an Internet-Based Screening Program

Urogenital and rectal specimens collected from the "IWantTheKit" Internet-based sexually transmitted infection screening program were evaluated for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Of 881 paired specimens submitted from August 2013 to December 2016, 15.0% (n = 132) tested positive for 1 or more sexually transmitted infections, of which 50.8% (n = 67) were identified exclusively through rectal testing.

Implementation Strategies to Increase PrEP Uptake in the South

PURPOSE OF REVIEW

Seven years after TDF/FTC was approved for pre-exposure prophylaxis to reduce risks of HIV infection, there have been large increases in the number of persons using PrEP in the USA. However, recent data on pre-exposure prophylaxis (PrEP) use at the state level indicate that people living in the Southern United States are underserved by PrEP relative to their epidemic need. We sought to review possible reasons for inequitable uptake of PrEP in the South and identify implementation approaches to increase PrEP uptake in the South.

RECENT FINDINGS

Published literature, data on the locations of PrEP service providers, recent data on PrEP utilization from pharmacy prescription databases, HIV surveillance data and government data on healthcare providers, and health literacy indicate a confluence of factors in the South that are likely limiting PrEP uptake. A variety of approaches are needed to address the complex challenges to PrEP implementation in the South. These include considering alternative PrEP provision strategies (e.g., pharmacy-based PrEP, telemedicine-delivered PrEP), conducting gain-based stigma-reduction campaigns, increasing capacity for reimbursement for PrEP medications and services through policy change to expand Medicaid and to preserve access to Affordable Care Act-compliant health plans, expanding STI screening programs and improving integration of PrEP offering with delivery of positive STI results, using mHealth tools to screen groups at highest risk for HIV (e.g., men who have sex with men) periodically to increase correct perception of risk, and streamlining clinical procedures to allow same-day PrEP starts for patients without obvious medical contraindications. Overcoming the structural, capacity, and policy challenges to increasing PrEP uptake in the South will require innovations in clinical approaches, leveraging technologies, and policy changes. The South has unique challenges to achieving equitable PrEP uptake, and addressing key barriers to expanded PrEP use will require multisectoral responses.