Health Care Provider Perceptions of a Sexually Transmitted Infection Self-testing Program in an HIV Care Clinic

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.

Facilitators and Barriers to the Implementation of Interventions in Washington, DC, to Improve Sexually Transmitted Infection Screening, Testing, and Treatment Among People with or at Risk of HIV

Bacterial sexually transmitted infection (STI) incidences of gonorrhea, chlamydia, and syphilis are increasing in Washington, DC. Moreover, the availability of HIV pre-exposure prophylaxis for people at risk of HIV and condomless sex has increased, and bacterial STI rates have risen. This indicates the necessity of evidence-based strategies to ensure access to STI care and improve health outcomes for people with HIV in Washington, DC. Three clinics in Washington, DC, implemented three evidence-based interventions, including the use of a standardized audio computer-assisted self-interview to obtain an interval sexual history at each clinic visit, patient self-collection of chlamydia/gonorrhea nucleic acid amplification test specimens, and sexual minority welcoming clinical space indicators to normalize STI screening and testing. Three sites in Washington, DC, used a multi-level socioecological model to identify successes, challenges, and lessons learned from program implementation at the following three levels: (1) individual, (2) interpersonal, and (3) public policy. We conclude with a series of instructional strategies that may be useful for the implementation of similar interventions that may assist district-wide responses to decrease health disparities and increase STI prevention.

Uptake and provision of self-care interventions for sexual and reproductive health: findings from a global values and preferences survey

Self-care interventions hold the potential to improve sexual and reproductive health (SRH) and well-being. Yet key knowledge gaps remain regarding how knowledge and uptake vary across different types of self-care interventions. There is also limited understanding of health workers’ confidence in promoting SRH self-care interventions, and how this may differ based on personal uptake experiences. To address these knowledge gaps, we conducted a web-based cross-sectional survey among health workers and laypersons from July to November 2018. We investigated the following information about SRH self-care interventions: knowledge and uptake; decisions for use; and associations between health workers’ uptake and providing prescriptions, referrals, and/or information for these interventions. Participants (n = 837) included laypersons (n = 477) and health workers (n = 360) from 112 countries, with most representation from the WHO European Region (29.2%), followed by the Americas (28.4%) and African (23.2%) Regions. We found great heterogeneity in knowledge and uptake by type of SRH self-care intervention. Some interventions, such as oral contraception, were widely known in comparison with interventions such as STI self-sampling. Across interventions, participants perceived benefits of privacy, convenience, and accessibility. While pharmacies and doctors were preferred access points, this varied by type of self-care intervention. Health workers with knowledge of the self-care intervention, and who had themselves used the self-care intervention, were significantly more likely to feel confident in, and to have provided information or referrals to, the same intervention. This finding signals that health workers can be better engaged in learning about self-care SRH interventions and thereby become resources for expanding access.

A Systematic Review of New Approaches to Sexually Transmitted Infection Screening Framed in the Capability, Opportunity, Motivation, and Behavior Model of Implementation Science

ABSTRACT

Chlamydia and gonorrhea are 2 of the most common bacterial sexually transmitted infections (STIs) worldwide. Rising chlamydia and gonorrhea rates along with increased closing of STI clinics has led many to seek STI testing in clinical settings such as urgent cares and walk-in clinics. However, with competing priorities, providing effective and efficient STI care can be difficult in these settings. This has left a growing need for the implementation of novel STI screening programs in other clinical settings. This review summarizes previous studies that have evaluated the clinical implementation of chlamydia and gonorrhea screening programs in these settings. Literature from January 2015 to February 2020 regarding the implementation or evaluation of STI screening programs in clinical settings was reviewed. Constructs from the Capability, Opportunity, Motivation, and Behavior model were used to organize results, as this model can aid in identifying specific strategies for behavior/process change interventions. We found that multiple STI screening programs have been implemented and evaluated in 5 different countries and multiple health care facilities including sexual health clinics, urgent cares, walk-in clinics, and university health clinics. When implementing new STI screening programs, sample-first, test-and-go services and molecular point-of-care (POC) testing approaches were found to be effective in increasing screening and reducing costs and time to treatment. At the health care systems level, these programs can help reduce STI screening costs and generate additional revenue for clinics. At the provider level, clear communication and guidance can help clinical and administrative staff in adopting new screening programs. Finally, at the patient level, new programs can reduce time to treatment and travel costs in visiting clinics multiple times for testing and treatment services.

Extragenital Testing for Neisseria gonorrhoeae and Chlamydia trachomatis in a Large HIV Clinic in the US South: Implementation and Epidemiology

BACKGROUND

Rectal and oral Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infections are common among people with HIV, especially men who have sex with men (MSM); however, GC/CT testing rates remain low in many HIV clinics. We evaluated the real-world implementation and results of extragenital nucleic acid amplification testing for GC/CT in an urban HIV clinic.

METHODS

Electronic health records were reviewed for all patients 18 years or older with ≥1 outpatient visit to an HIV clinic in Dallas, TX, from February 2016 to May 2019. Extragenital nucleic acid amplification testing became available in February 2017, which was followed by active interventions to increase testing.

RESULTS

Overall, 5564 individual patients were included in the preintervention period (February 2016-January 2017), 5067 in the intervention period (February 2017-August 2017), and 7030 in the postintervention period (September 2017-May 2018). Tailored education was provided to patients, and nursing and medical providers, and a self-collection protocol was implemented beginning in spring 2017. A sustained increase in extragenital GC/CT testing among MSM patients, from 70% to 87% (P < 0.01), was observed. Among MSM, overall GC positivity increased from 3.2% to 8.5% and CT positivity increased from 3.9% to 8.3%. N. gonorrhoeae/C. trachomatis infections were highest among young (<35 years) MSM, and approximately 50% of GC/CT infections diagnosed were detected by oral and rectal tests.

CONCLUSIONS

Clinic-wide education and self-collection of extragenital specimens were associated with increased GC/CT testing and detection in a large HIV clinic.

Pilot implementation of a home-care programme with chlamydia, gonorrhoea, hepatitis B, and syphilis self-sampling in HIV-positive men who have sex with men

Background

Not all men who have sex with men (MSM) at risk for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) infection currently receive sexual healthcare. To increase the coverage of high-quality HIV/STI care for MSM, we developed a home-care programme, as extended STI clinic care. This programme included home sampling for testing, combined with treatment and sexual health counselling. Here, we pilot implemented the programme in a hospital setting (HIV-positive MSM) to determine the factors for the successful implementation of STI home sampling strategies.

Methods

Healthcare providers from the HIV hospital treatment centre (Maastricht) were invited to offer free STI sampling kits (syphilis, hepatitis B, [extra]genital chlamydia and gonorrhoea laboratory testing) to their HIV-positive MSM patients (March to May 2018). To evaluate implementation of the program, quantitative and qualitative data were collected to assess adoption (HIV care providers offered sampling kits to MSM), participation (MSM accepted the sampling kits) and sampling-kit return, STI diagnoses, and implementation experiences.

Results

Adoption was 85.3% (110/129), participation was 58.2% (64/110), and sampling-kit return was 43.8% (28/64). Of the tested MSM, 64.3% (18/28) did not recently (< 3 months) undergo a STI test; during the programme, 17.9% (5/28) were diagnosed with an STI. Of tested MSM, 64.3% (18/28) was vaccinated against hepatitis B. MSM reported that the sampling kits were easily and conveniently used. Care providers (hospital and STI clinic) considered the programme acceptable and feasible, with some logistical challenges. All (100%) self-taken chlamydia and gonorrhoea samples were adequate for testing, and 82.1% (23/28) of MSM provided sufficient self-taken blood samples for syphilis screening. However, full syphilis diagnostic work-up required for MSM with a history of syphilis (18/28) was not possible in 44.4% (8/18) of MSM because of insufficient blood sampled.

Conclusion

The home sampling programme increased STI test uptake and was acceptable and feasible for MSM and their care providers. Return of sampling kits should be further improved. The home-care programme is a promising extension of regular STI care to deliver comprehensive STI care to the home setting for MSM. Yet, in an HIV-positive population, syphilis diagnosis may be challenging when using self-taken blood samples.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05658-4.

Improving STD service delivery: Would American patients and providers use self-tests for gonorrhea and chlamydia?

Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) are the most frequently reported notifiable diseases in the United States and costs for diagnosis and treatment of these two infections are approximately $700 million per year. A proposed new method for screening for these two infections is self-tests; similar to at-home pregnancy and HIV tests which do not include sending collected specimens to a laboratory for diagnosis. However, no such self-tests for sexually transmitted diseases (STD) have been approved by the Food and Drug Administration (FDA). To determine the acceptability of such a test, we used three surveys, conducted in 2017, including the American Men's Internet Survey, the SummerStyles survey, and the DocStyles survey to ask potential users about their interest in this type of test and how they might use it. Among our sampled population of men who have sex with men, 79.5% said they would prefer to take this type of test at home and 73.9% said they would be willing to pay at least $20 for the test. Among young adults (18-29 years), 54.1% indicated that they would like to take this test at home and 64.5% were willing to pay more than $10 for such a test. Among sampled physicians, 85.1% were "likely" or "very likely" to use an FDA-approved STD self-test in their office to screen for CT or GC. Self-tests for STDs are on our horizon and we need to be prepared to integrate these tests into our healthcare systems.