Comparing the characteristics of users of an online service for STI self-sampling with clinic service users: a cross-sectional analysis

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.

Moving Toward Online-Based Sexually Transmitted Infection Testing and Treatment Services for Young People: Who Will Use It and What Do They Want?

BACKGROUND

The market for online sexually transmitted infection (STI) services is rapidly expanding. Online health services often have unequal uptake among different demographics of the population. There is a need to understand how different online delivery options for STI testing may appeal to different groups of young people, particularly young people who have higher rates of STI diagnoses.

METHODS

An online survey of young Australians aged 16 to 29 years was conducted to understand service preferences regarding consultation (telehealth, fully automated questionnaire), testing (electronic pathology form, at-home self-sampling), and treatment (e-prescriptions, mailed oral tablets). Multivariable multinomial logistic regression examined associations between user characteristics and service preferences, and adjusted relative risk ratios (aRRRs) and 95% confidence intervals (CIs) are presented.

RESULTS

Among 905 respondents, rural youth were more likely to prefer fully automated questionnaires (aRRR, 1.9; 95% CI, 1.0-3.5) over telehealth consultations, whereas culturally and linguistically diverse (CALD) youth were less likely (aRRR, 0.4; 95% CI, 0.2-0.7). Rural youth preferred at-home self-sampling kits (aRRR, 1.9; 95% CI, 1.3-2.7) over electronic forms for on-site collection at pathology centers, with the opposite for CALD youth (aRRR, 0.7; 95% CI, 0.5-1.0). Receiving oral antibiotics by mail was preferred by rural youth (aRRR, 2.3; 95% CI, 1.1-4.6) over for in-clinic treatment, but not for CALD youth (aRRR, 0.5; 95% CI, 0.4-0.8).

CONCLUSIONS

Our findings suggest that rural youth tend to prefer self-navigated and automated options, whereas CALD prefer options with greater provider engagement. Online STI service providers should consider how different service options may affect equitable uptake across the population and implications for addressing disparities in testing and treatment.

Differential uptake and effects of digital sexually transmitted and bloodborne infection testing interventions among equity-seeking groups: a scoping review

BACKGROUND

Digital sexually transmitted and bloodborne infection (STBBI) testing interventions have gained popularity. However, evidence of their health equity effects remains sparse. We conducted a review of the health equity effects of these interventions on uptake of STBBI testing and explored design and implementation factors contributing to reported effects.

METHODS

We followed Arksey and O'Malley's framework for scoping reviews (2005) integrating adaptations by Levac et al (2010). We searched OVID Medline, Embase, CINAHL, Scopus, Web of Science, Google Scholar and health agency websites for peer-reviewed articles and grey literature comparing uptake of digital STBBI testing with in-person models and/or comparing uptake of digital STBBI testing among sociodemographic strata, published in English between 2010 and 2022. We extracted data using the Place of residence, Race, Occupation, Gender/Sex, Religion, Education, Socioeconomic status (SES), Social capital and other disadvantaged characteristics (PROGRESS-Plus) framework, reporting differences in uptake of digital STBBI testing by these characteristics.

RESULTS

We included 27 articles from 7914 titles and abstracts. Among these, 20 of 27 (74.1%) were observational studies, 23 of 27 (85.2%) described web-based interventions and 18 of 27 (66.7%) involved postal-based self-sample collection. Only three articles compared uptake of digital STBBI testing with in-person models stratified by PROGRESS-Plus factors. While most studies demonstrated increased uptake of digital STBBI testing across sociodemographic strata, uptake was higher among women, white people with higher SES, urban residents and heterosexual people. Co-design, representative user recruitment, and emphasis on privacy and security were highlighted as factors contributing to health equity in these interventions.

CONCLUSION

Evidence of health equity effects of digital STBBI testing remains limited. While digital STBBI testing interventions increase testing across sociodemographic strata, increases are lower among historically disadvantaged populations with higher prevalence of STBBIs. Findings challenge assumptions about the inherent equity of digital STBBI testing interventions, emphasising the need to prioritise health equity in their design and evaluation.

STI testing, diagnoses and online chlamydia self-sampling among young people during the first year of the COVID-19 pandemic in England

PURPOSE

COVID-19 control measures reduced face-to-face appointments at sexual health services (SHSs). Remote access to SHSs through online self-sampling was increased. This analysis assesses how these changes affected service use and STI testing among 15-24 year olds ('young people') in England.

METHODS

Data on all chlamydia, gonorrhoea and syphilis tests from 2019-2020, among English-resident young people were obtained from national STI surveillance datasets. We calculated proportional differences in tests and diagnoses for each STI, by demographic characteristics, including socioeconomic deprivation, between 2019-2020. Binary logistic regression was used to determine crude and adjusted odds ratios (OR) between demographic characteristics and being tested for chlamydia by an online service.

RESULTS

Compared to 2019, there were declines in testing (chlamydia-30%; gonorrhoea-26%; syphilis-36%) and diagnoses (chlamydia-31%; gonorrhoea-25%; syphilis-23%) among young people in 2020. Reductions were greater amongst 15-19 year-olds vs. 20-24 year-olds. Amongst people tested for chlamydia, those living in the least deprived areas were more likely to be tested using an online self-sampling kit (males; OR = 1.24 [1.22-1.26], females; OR = 1.28 [1.27-1.30]).

CONCLUSION

The first year of the COVID-19 pandemic in England saw declines in STI testing and diagnoses in young people and disparities in the use of online chlamydia self-sampling which risk widening existing health inequalities.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

STI testing and subsequent clinic attendance amongst test negative asymptomatic users of an internet STI testing service; one-year retrospective study

AIM

To explore the characteristics of online STI test users, and assess the frequency and factors associated with subsequent service use following a negative online STI test screen in individuals without symptoms.

METHODS

One-year retrospective study of online and clinic STI testing within a large integrated sexual health service (Umbrella in Birmingham and Solihull, England) between January and December 2017. A multivariable analysis of sociodemographic and behavioural characteristics of patients was conducted. Sexual health clinic appointments occurring within 90 days of a negative STI test, in asymptomatic individuals who tested either online or in clinic were determined. Factors associated with online STI testing and subsequent clinic use were determined using generalized estimating equations and reported as odds ratios (OR) with corresponding 95% confidence intervals (CI).

RESULTS

31 847 online STI test requests and 40 059 clinic attendances incorporating STI testing were included. 79% (25020/31846) of online STI test users and 49% (19672/40059) of clinic STI test takers were asymptomatic. Online STI testing was less utilised (p<0.05) by men who have sex with men (MSM), non-Caucasians and those living in neighborhoods of greater deprivation. Subsequent clinic appointments within 90 days of an asymptomatic negative STI test occurred in 6.2% (484/7769) of the online testing group and 33% (4960/15238) for the clinic tested group. Re-attendance following online testing was associated with being MSM (aOR 2.55[1.58 to 4.09]-MSM vs Female) and a recent prior history of STI testing (aOR 5.65[4.30 to 7.43] 'clinic tested' vs 'No' recent testing history).

CONCLUSIONS

Subsequent clinic attendance amongst online STI test service users with negative test results was infrequent, suggesting that their needs were being met without placing an additional burden on clinic based services. However, unequal use of online services by different patient groups suggests that optimised messaging and the development of online services in partnership with users are required to improve uptake.

Dispositifs de dépistage des infections sexuellement transmissibles à domicile : quelle prise en compte des populations LGBT ?

INTRODUCTION

Every days, more than one million people are infected with a sexually transmitted infection worlwide. In France, screening mainly rely on medical laboratories, private or public, with e prescription. Those tests face structural ans social barriers for LGBT people that could be partially lifted using at home self sampling. Using a narrative review, we will study how the needs of those populations are adressed in existing at home self sampling interventions.

PURPOSE OF RESEARCH

Describe the adaptation of home sampling system to MSM, WSW and transgender peoples.

RESULTS

Nine interventions met our inclusion criteria, eight in English spoken countries. Studies did not systematically reported data on sexual orientation. Transgender people, when identified, were rarely a larger group enough to be the subject of sub-analysis. Infections tested were CT and NG for three intervention, HIV only for one, CT,NG and HIV for five, and one also add HCV.

CONCLUSIONS

Standing as a complement to physical testing services, at home self-sampling intervention could benefit from an advertisement to WSW and from the integration of wider sexual health services.

Access to, usage and clinic outcomes of, online postal sexually transmitted infection services: a scoping review

BACKGROUND

There has been considerable expansion in online postal self-sampling (OPSS) STI services in many parts of the UK, driven by increasing demand on sexual health services and developments in diagnostics and digital health provision. This shift in service delivery has occurred against a backdrop of reduced funding and service fragmentation and the impact is unknown. We explored characteristics of people accessing and using OPSS services for STIs in the UK, the acceptability of these services and their impact on sexual health inequalities.

METHODS

A scoping review was conducted of studies published in English-language based on pre-agreed inclusion/exclusion criteria, between 01 January 2010 and 07 July 2021. Nine databases were searched, and 23 studies that met the eligibility criteria were included. Studies were appraised using the Mixed Methods Appraisal Tool.

RESULTS

Study designs were heterogeneous, including quantitative, qualitative and mixed-methods analyses. The majority were either evaluating a single-site/self-sampling provider, exploratory or observational and of variable quality. Few studies collected comprehensive user demographic data. Individuals accessing OPSS tended to be asymptomatic, of white ethnicity, women, over 20 years and from less deprived areas. OPSS tended to increase overall STI testing demand and access, although return rates for blood samples were low, as was test positivity. There were varied results on whether services reduced time to treatment. OPSS services were acceptable to the majority of users. Qualitative studies showed the importance of trust, confidentiality, discretion, reliability, convenience and improved patient choice.

CONCLUSION

OPSS services appear highly acceptable to users. However, uptake appears to be socially patterned and some groups who bear a disproportionate burden of poor sexual health in the UK are under-represented among users. Current provision of online self-sampling could widen health inequalities, particularly where other options for testing are limited. Work is needed to fully evaluate the impact and cost-effectiveness of OPSS services.

HIV and STI Testing Preferences for Men Who Have Sex with Men in High-Income Countries: A Scoping Review

Background: Regular testing for HIV and other sexually transmitted infections (STI) is recommended at least annually for sexually active men who have sex with men (MSM) in most high-income countries. To encourage regular use of HIV and STI testing and treatment services for MSM, we reviewed the literature to summarise the attributes of an HIV/STI testing service that MSM prefer. Method: We conducted a scoping review, searching PubMed, EMBASE, PsycINFO and CINAHL in January 2020 for articles reporting primary data on the preferences of MSM (living in high-income countries) for HIV/STI testing services. Two reviewers independently screened titles and abstracts and any discrepancies were resolved by a third reviewer. We extracted data on the service attributes that MSM preferred and summarised these thematically using a socioecological framework. Results: In total, 1464 publications were identified, 220 full texts were read and 57 were included in the final analysis. We found 21 articles addressing ‘individual’ attributes, 50 articles addressing ‘service’ attributes and 17 articles addressing ‘societal’ attributes. The key themes of preferences for HIV/STI testing services were: (1) the appeal of self-testing due to convenience and privacy; (2) the need to provide a variety of testing options; and (3) the influence of the testing experience, including confidentiality and privacy, tester characteristics and stigma. There were distinct patterns of preferences for subpopulations of MSM across studies, such as the preference of self-testing for young MSM, and of in-clinic testing for those who perceived themselves as high risk (i.e., with symptoms of STIs or exposed to a partner living with HIV). Conclusion: To make HIV/STI testing more accessible for MSM and encourage regular screening, it is important to address ‘individual’, ‘service’ and ‘societal’ attributes, such as enhancing the convenience of testing through self-testing, and providing a service that men feel comfortable and safe accessing. Furthermore, services should accommodate the preferences of diverse sub-populations within the MSM community.

Direct Access for Patients to Diagnostic Testing and Results Using eHealth: Systematic Review on eHealth and Diagnostics

BACKGROUND

The number of people with chronic diseases and the subsequent pressure on health care is increasing. eHealth technology for diagnostic testing can contribute to more efficient health care and lower workload.

OBJECTIVE

This systematic review examines the available methods for direct web-based access for patients to diagnostic testing and results in the absence of a health care professional in primary care.

METHODS

We searched the PubMed, Embase, Web of Sciences, Cochrane Library, Emcare, and Academic Search Premier databases in August 2019 and updated in July 2021. The included studies focused on direct patient access to web-based triage leading to diagnostic testing, self-sampling or testing, or web-based communication of test results. A total of 45 studies were included. The quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Most studies had a quantitative descriptive design and discussed a combination of services. Diagnostic test services mainly focused on sexually transmitted infections. Overall, the use was high for web-based triage (3046/5000, >50%, who used a triage booked a test), for self-sampling or self-testing kits (83%), and the result service (85%). The acceptability of the test services was high, with 81% preferring home-based testing over clinic-based testing. There was a high rate of follow-up testing or treatment after a positive test (93%).

CONCLUSIONS

The results show that direct access to testing and result services had high use rates, was positively evaluated, and led to high rates of follow-up treatment. More research on cost-effectiveness is needed to determine the potential for other diseases. Direct access to diagnostic testing can lower the threshold for testing in users, potentially increase efficiency, and lower the workload in primary care.

Law, human rights and gender in practice: an analysis of lessons from implementation of self-care interventions for sexual and reproductive health

Self-care interventions for health are becoming increasingly available, and among the preferred options, including during the COVID-19 pandemic. This research assessed the extent of attention to laws and policies, human rights and gender in the implementation of self-care interventions for sexual and reproductive health (SRH), to identify where additional efforts to ensure an enabling environment for their use and uptake will be useful. A literature review of relevant studies published between 2010 and 2020 was conducted using PubMed, Scopus and Web of Science. Relevant data were systematically abstracted from 61 articles. In March–April 2021, semi-structured interviews were conducted with 10 key informants, selected for their experience implementing self-care interventions for SRH, and thematically analysed. Laws and policies, rights and gender are not being systematically addressed in the implementation of self-care interventions for SRH. Within countries, there is varied attention to the enabling environment including the acceptability of interventions, privacy, informed consent and gender concerns as they impact both access and use of specific self-care interventions, while other legal considerations appear to have been under-prioritised. Operational guidance is needed to develop and implement supportive laws and policies, as well as to ensure the incorporation of rights and gender concerns in implementing self-care interventions for SRH.

Photodiagnosis of genital herpes and warts within a specialist online sexual health service: an observational (mixed methods) study of user experience and clinical outcomes

OBJECTIVES

To evaluate the feasibility and acceptability of a pilot, free, online photodiagnosis service for genital herpes and warts with postal treatment delivered by a specialist digital sexual health service.

SETTING

An online sexual health service available free of charge in South East London, UK.

PARTICIPANTS

Routinely collected data from 237 users of the pilot service during the study period and qualitative interviews with a purposive sample of 15 users.

INTERVENTION

A pilot, free, online photodiagnosis service for genital herpes and warts with postal treatment delivered by a specialist digital sexual health service.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of users who successfully uploaded photographs and the proportion diagnosed, treated and referred to face-to-face clinical services. User experience of this service.

RESULTS

The service was accessed by 237 users during the study period with assessment possible for 86% of users based on the photographs provided. A diagnosis of genital herpes or warts was made for 40.5% and 89.6% were subsequently treated through the service. Eighteen per cent were diagnosed as normal/not needing treatment and 42% were signposted to clinic for further clinical assessment.Qualitative data showed that users felt able and willing to provide genital images for diagnosis. Those who were treated or reassured expressed high satisfaction with the service, valuing the convenience, discreetness and support provided. However, users, particularly those who required referral to other services requested more personal and detailed communication when a clinical diagnosis is given remotely.

CONCLUSIONS

Findings suggest that online photodiagnosis was feasible and acceptable. However, effective and acceptable management of those who require referral needs careful remote communication.

Acceptability and usability of HIV self-tests in two European countries: findings from surveys of clients at non-governmental organisations in Lithuania and Italy

Background

Uptake of HIV self-tests (HIVST) remains low in Europe. We conducted two separate surveys to understand facilitators and barriers to the use of HIVST in two European countries, as part of the EU INTEGRATE Joint Action. In both countries, HIV has been legal since 2016. In Lithuania, where HIVST sales have been low, the survey primarily assessed acceptability whilst in Italy, with better HIVST uptake, usability was the focus.

Methods

Participants were recruited through community HIV testing sites, and in Lithuania also through social media. In Lithuania, participants self-completed a survey on their testing history, and attitudes toward and experiences with self-testing. In Italy participants performed an HIVST (Mylan Autotest) while being observed by a community health worker (CHW). Both participants and CHW completed a self-administered survey evaluating the experience of the participant.

Results

In Lithuania, awareness of HIV self-testing (75%) was high among the 138 people who completed the survey. Privacy and confidentiality (70%) was the most common reason to use an HIVST whilst cost was reported as the main barrier by 60%, only 15% were willing to pay the current price. Almost half (42%) were concerned about doing the test incorrectly and 36% preferred that a trained person could discuss their result. Purchasing HIVST at a pharmacy (70%) or online (61%) was favoured and 68% would opt to simultaneously test for other infections.

In Italy, 28 people who had never used an HIVST before were observed using one. 43% found the test easy to use but CHWs reported that 36% of participants failed at least one step. The quick result (68%) was the most common reason to use one again, yet the main concerns were the lack of counselling (50%) and reading result alone (32%).

Conclusions

HIVST are acceptable and usable, however cost is a major barrier. Local and national strategies are needed to increase awareness of and access to HIVST and target HIVST campaigns toward key risk groups such as MSM. Meanwhile, steps can be taken to improve testing instructions and support for self-testers. Offering multiplex testing for other infections would also likely increase uptake.

HIV self-testing with digital supports as the new paradigm: A systematic review of global evidence (2010-2021)

BACKGROUND

HIV self-testing (HIVST) is recommended by the WHO as an innovative strategy to reach UNAIDS targets to end HIV by 2030. HIVST with digital supports is defined as the use of digital interventions (e.g., website-based, social media, mobile HIVST applications (apps), text messaging (SMS), digital vending machines (digital VMs)) to improve the efficiency and impact of HIVST. HIVST deployment and integration in health services is an emerging priority. We conducted a systematic review aiming to close the gap in evidence that summarizes the impact of digitally supported HIVST and to inform policy recommendations.

METHODS

We searched PubMed and Embase for articles and abstracts on HIVST with digital supports published during the period February 1st, 2010 to June 15th, 2021, following Cochrane guidelines and PRISMA methodology. We assessed feasibility, acceptability, preference, and impact outcomes across all populations and study designs. Metrics reported were willingness to use HIVST, preferences for HIVST delivery, proportion of first-time testers, HIVST uptake, HIVST kit return rate, and linkage to care. Heterogeneity of the interventions and reported metrics precluded us from conducting a meta-analysis.

FINDINGS

46 studies were narratively synthesized, of which 72% were observational and 28% were RCTs. Half of all studies (54%, 25/46) assessed web-based innovations (e.g., study websites, videos, chatbots), followed by social media (26%, 12/46), HIVST-specific apps (7%, 3/46), SMS (9%, 4/46), and digital VMs (4%, 2/46). Web-based innovations were found to be acceptable (77-97%), preferred over in-person and hybrid options by more first-time testers (47-48%), highly feasible (93-95%), and were overall effective in supporting linkage to care (53-100%). Social media and app-based innovations also had high acceptability (87-95%) and linkage to care proportions (80-100%). SMS innovations increased kit return rates (54-94%) and HIVST uptake among hard-to-reach groups. Finally, digital VMs were highly acceptable (54-93%), and HIVST uptake was six times greater when using digital VMs compared to distribution by community workers.

INTERPRETATION

HIVST with digital supports was deemed feasible, acceptable, preferable, and was shown to increase uptake, engage first-time testers and hard-to-reach populations, and successfully link participants to treatment. Findings pave the way for greater use of HIVST interventions with digital supports globally.

What do young people in high-income countries want from STI testing services? A systematic review

BACKGROUND

There are upward trends of STI rates among young people in most high-income countries. We reviewed the literature to provide a summary of information to support health services with the aim of increasing testing of STIs among young people living in high-income countries.

METHODS

We conducted a systematic review (Prospero: CRD42020179720) using PubMed, Embase, PsychINFO and CINAHL. The search was performed on 10 January 2020 for studies between January 2000 and 10 January 2020. Two reviewers independently screened articles, and any discrepancies were resolved by a third reviewer. Studies were included if they were performed in high-income countries and contained data on both young people (<26 years) and STI testing preferences. Data regarding the characteristics of STI testing services that young people preferred was extracted. We categorised these characteristics using the framework of a social-ecological model.

RESULTS

We identified 1440 studies, and 63 studies were included in the final review. We found 32 studies that addressed individual factors, 62 studies that addressed service factors and 17 studies that addressed societal factors. At an individual level, we identified eight attributes including the need for improved sexual health education. At a service level, 14 attributes were identified including preferences from different subgroups of young people (such as sexual and ethnic minorities) for the types of services. At a societal level, we identified two attributes including the need to address stigma associated with STIs.

CONCLUSION

We provide an overview of the growing body of literature capturing the preferences of young people for STI testing services. To optimise the uptake of STI testing among young people, factors from all socioecological levels should be considered. In addition, understanding and accounting for distinct preferences from subgroups of young people could increase demand for STI testing services for those at greatest need.

Prevalence of hepatitis B immunity and infection in home self-sampling HIV service users

Objectives

Although hepatitis B virus (HBV) vaccination for high-risk groups including gay, bisexual and other men who have sex with men (MSM) is recommended in the UK, data on HBV immunisation coverage are limited. This study aimed to understand the prevalence of HBV infection, susceptibility and immunity due to immunisation among a high-risk population of MSM and heterosexuals who are less likely to attend sexual health services.

Methods

Residual HIV-negative serology samples archived from a national HIV self-sampling service in 2016 were tested for HBV markers using an unlinked anonymous approach. Prevalence of HBV infection, evidence of immunisation and susceptibility were calculated and stratified by individuals’ characteristics. Multinomial logistic regression was used to estimate relative risk ratios (RRRs) associated with covariates.

Results

Of 2172 samples tested, 1497 (68.9%) were from MSM and 657 (30.2%) were from heterosexuals. Susceptibility to HBV infection was 66.1% among MSM and 77.0% among heterosexuals. Only 29.9% of MSM and 17.4% of heterosexuals had serological evidence of immunisation. Current infection was 1.1% in heterosexuals and 0.2% in MSM. Adjusted analysis showed evidence of immunisation was lower among heterosexuals (RRR 0.66, 95% CI 0.50 to 0.86) and those with no previous HIV test (RRR 0.41, 95% CI 0.31 to 0.54), and higher in those of other white or other ethnicity.

Conclusions

Among MSM and heterosexual users of a self-sampling HIV service, evidence of immunisation to HBV infection was low and susceptibility to infection was comparatively high, suggesting suboptimal delivery of HBV immunisation in sexual health services.

How can we make self-sampling packs for sexually transmitted infections and bloodborne viruses more inclusive? A qualitative study with people with mild learning disabilities and low health literacy

Objectives

1.5 million people in the UK have mild to moderate learning disabilities. STIs and bloodborne viruses (BBVs) are over-represented in people experiencing broader health inequalities, which include those with mild learning disabilities. Self-managed care, including self-sampling for STIs/BBVs, is increasingly commonplace, requiring agency and health literacy. To inform the development of a partner notification trial, we explored barriers and facilitators to correct use of an STI/BBV self-sampling pack among people with mild learning disabilities.

Methods

Using purposive and convenience sampling we conducted four interviews and five gender-specific focus groups with 25 people (13 women, 12 men) with mild learning disabilities (July–August 2018) in Scotland. We balanced deductive and inductive thematic analyses of audio transcripts to explore issues associated with barriers and facilitators to correct use of the pack.

Results

All participants found at least one element of the pack challenging or impossible, but welcomed the opportunity to undertake sexual health screening without attending a clinic and welcomed the inclusion of condoms. Reported barriers to correct use included perceived overly complex STI/BBV information and instructions, feeling overwhelmed and the manual dexterity required for blood sampling. Many women struggled interpreting anatomical diagrams depicting vulvovaginal self-swabbing. Facilitators included pre-existing STI/BBV knowledge, familiarity with self-management, good social support and knowing that the service afforded privacy.

Conclusion

In the first study to explore the usability of self-sampling packs for STI/BBV in people with learning disabilities, participants found it challenging to use the pack. Limiting information to the minimum required to inform decision-making, ‘easy read’ formats, simple language, large font sizes and simpler diagrams could improve acceptability. However, some people will remain unable to engage with self-sampling at all. To avoid widening health inequalities, face-to-face options should continue to be provided for those unable or unwilling to engage with self-managed care.

Performance of a tool to identify different types of self-reported sexual risk among women attending a contraception and sexual health clinic: results of a cross-sectional survey

INTRODUCTION

A clinical prediction rule (CPR) using psychosocial questions was previously derived to target sexual healthcare in general practice by identifying women at risk of unintended pregnancy (UIP) and sexually transmitted infections (STIs). This psychosocial CPR may help target resources within contraception and sexual health (CASH) services. This study investigated how well it predicted recent self-reported risk of UIP and STI acquisition among women attending a CASH clinic.

METHODS

Female patients aged 16-44 years attending a CASH clinic in South-East England were offered a questionnaire on arrival. This comprised psychosocial questions, and others addressing three sexual risks: (1) two or more male sexual partners in the last year (2+P), (2) risk of STI acquisition through most recent partner and (3) risk of UIP in the last 6 months. A CPR score was calculated for each participant and cross-tabulated against self-report of each sexual risk to estimate CPR sensitivity and specificity.

RESULTS

The psychosocial questions predicting 2+P had sensitivity 83.2% (95% CI 79.3% to 86.5%) and specificity 56.1% (95% CI 51.3%-60.6%). Those predicting combined 2+P and/or risk of STI acquisition through most recent partner had a sensitivity of 89.1% (95% CI 85.7%-91.8%) and specificity of 43.7% (95% CI 39.0%-48.5%). Questions predicting risk of UIP in the last 6 months had a sensitivity of 82.5% (95% CI 78.6%-86.0%) and specificity of 48.3% (95% CI 43.4%-53.1%).

CONCLUSIONS

The CPR demonstrated good sensitivity but low specificity, so may be suited to triaging or stratifying which interventions to offer CASH patients and by which mode (eg, online vs face-to-face). Further investigation of causal links between psychosocial factors and sexual risk is warranted to support development of psychosocial interventions for this patient group.

Does online sexually transmitted infection screening compromise care? A service evaluation comparing the management of chlamydial infection diagnosed online and in clinic

Patient demand on sexual health services in the United Kingdom is so high that many services have introduced online screening to accommodate more patients. There are concerns that these services may not be accessible to all. This service evaluation was undertaken to determine whether online screening is accessible by those patients most at need by comparing the demographics and number of asymptomatic chlamydial infections detected online and in clinic. No difference was found in the age nor level of deprivation, demonstrating that online services are an accessible way to screen for sexually transmitted infections without overburdening established services.

'To be on the safe side': a qualitative study regarding users' beliefs and experiences of internet-based self-sampling for Chlamydia trachomatis and Neisseria gonorrhoeae testing

OBJECTIVES

In Sweden, an increasing number of tests for sexually transmitted infections are conducted. Self-sampling services are provided free of charge at the national eHealth website. Our aim was to obtain a deeper understanding of users' beliefs and experiences of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) self-sampling services.

METHODS

This qualitative study is part of the national project 'Internet-based chlamydia and gonorrhoea self-sampling test', conducted in Sweden. Individuals ordering a CT/NG self-sampling test at home from the eHealth website were invited to participate. Of the 114 individuals who agreed, a purposeful sample including 20 women and men aged 18-49 years (mean, 30.8 years) participated in a telephone interview in 2019.

RESULTS

The test service for CT/NG was highly appreciated by men and women of different ages. Round-the-clock accessibility, avoiding clinical visits, ease of use, confidentiality and a rapid test result were reasons for this appreciation. Language, uncertainty about the correct sampling procedure, unreliable postal services and concerns about handling of personal data were mentioned as barriers. Reasons for testing were checking after unprotected sex, symptoms, checking a partner's fidelity or a regular routine-'to be on the safe side'. Knowledge about the infections and their consequences was limited; some considered them severe, especially if they could threaten fertility, and others were less concerned. Disclosing an infection was described as emotionally stressful. Participants had high self-efficacy in relation to the test and would not hesitate to use the service again, even if it involved a cost.

CONCLUSIONS

Internet-based CT/NG self-sampling at home was highly appreciated and was used for individual health reasons, but also out of concern for others' health and for society as a whole. The benefits seem to outweigh the barriers, and the service may therefore continue to be widely offered.

A cohort study of the service-users of online contraception

BACKGROUND

In January 2017, the first free service providing oral contraceptive pills (OCPs) ordered online and posted home became available in the London boroughs of Lambeth and Southwark - ethnically and socioeconomically diverse areas with high rates of unplanned pregnancy. There are concerns that online services can increase health inequalities; therefore, we aimed to describe service-users according to age, ethnicity and Index of Multiple Deprivation (IMD) quintile of area of residence and to examine the association of these with repeated use.

METHODS

We analysed routinely collected data from January 2017 to April 2018 and described service-users using available sociodemographic factors and information on patterns of use. Logistic regression analysis examined factors associated with repeat ordering of OCPs.

RESULTS

The service was accessed by 726 individuals; most aged between 20 and 29 years (72.5%); self-identified as being of white ethnic group (58.8%); and residents of the first and second most deprived IMD quintiles (79.2%). Compared with those of white ethnic group, those of black ethnic group were significantly less likely to make repeat orders (adjusted OR 0.53, 95% CI 0.31 to 0.89; p=0.001), as were those of Asian and mixed ethnic groups.

CONCLUSIONS

These are the first empirical findings on free, online contraception and suggest that early adopters broadly reflect the population of the local area in terms of ethnic diversity and deprivation as measured by IMD. Ongoing service development should prioritise the identification and removal of barriers which may inhibit repeat use for black and minority ethnic groups.

Perceptions and Experiences of Internet-Based Testing for Sexually Transmitted Infections: Systematic Review and Synthesis of Qualitative Research

Background

Internet-based testing for sexually transmitted infections (STIs) allows asymptomatic individuals to order a self-sampling kit online and receive their results electronically, reducing the need to attend a clinic unless for treatment. This approach has become increasingly common; however, there is evidence that barriers exist to accessing it, particularly among some high-risk populations. We review the qualitative evidence on this topic, as qualitative research is well-placed to identify the complex influences that relate to accessing testing.

Objective

This paper aims to explore perceptions and experiences of internet-based testing for STIs among users and potential users.

Methods

Searches were run through 5 electronic databases (CINAHL, EMBASE, MEDLINE, PsycINFO, and Web of Science) to identify peer-reviewed studies published between 2005 and 2018. Search terms were drawn from 4 categories: STIs, testing or screening, digital health, and qualitative methods. Included studies were conducted in high-income countries and explored patient perceptions or experiences of internet-based testing, and data underwent thematic synthesis.

Results

A total of 11 studies from the 1735 studies identified in the initial search were included in the review. The synthesis identified that internet-based testing is viewed widely as being acceptable and is preferred over clinic testing by many individuals due to perceived convenience and anonymity. However, a number of studies identified concerns relating to test accuracy and lack of communication with practitioners, particularly when receiving results. There was a lack of consensus on preferred media for results delivery, although convenience and confidentiality were again strong influencing factors. The majority of included studies were limited by the fact that they researched hypothetical services.

Conclusions

Internet-based testing providers may benefit from emphasizing this testing’s comparative convenience and privacy compared with face-to-face testing in order to improve uptake, as well as alleviating concerns about the self-sampling process. There is a clear need for further research exploring in depth the perceptions and experiences of people who have accessed internet-based testing and for research on internet-based testing that explicitly gathers the views of populations that are at high risk of STIs.

Trial Registration

PROSPERO CRD42019146938; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=146938

Modelling patient flows and resource use within a sexual health clinic through discrete event simulation to inform service redesign

OBJECTIVES

Continuous improvement in the delivery of health services is increasingly being demanded in the UK at a time when budgets are being cut. Simulation is one approach used for understanding and assessing the likely impact of changes to the delivery of health services. However, little is known about the usefulness of simulation for analysing the delivery of sexual health services (SHSs). We propose a simulation method to model and evaluate patient flows and resource use within an SHS to inform service redesign.

METHODS

We developed a discrete event simulation (DES) model to identify the bottlenecks within the Unity SHS (Bristol, UK) and find possible routes for service improvement. Using the example of the introduction of an online service for sexually transmitted infection (STI) and HIV self-sampling for asymptomatic patients, the impact on patient waiting times was examined as the main outcome measure. The model included data such as patient arrival time, staff availability and duration of consultation, examination and treatment. We performed several sensitivity analyses to assess uncertainty in the model parameters.

RESULTS

We identified some bottlenecks under the current system, particularly in the consultation and treatment queues for male and female walk-in patients. Introducing the provision of STI and HIV self-sampling alongside existing services decreased the average waiting time (88 vs 128 min) for all patients and reduced the cost of staff time for managing each patient (£72.64 vs £88.74) compared with the current system without online-based self-sampling.

CONCLUSIONS

The provision of online-based STI and HIV self-sampling for asymptomatic patients could be beneficial in reducing patient waiting times and the model highlights the complexities of using this to cut costs. Attributing recognition for any improvement requires care, but DES modelling can provide valuable insights into the design of SHSs ensuing in quantifiable improvements. Extension of this method with the collection of additional data and the construction of more informed models seems worthwhile.

Factors associated with time to presentation for individuals with symptomatic uncomplicated genital gonorrhoea: a cross sectional cohort study of GToG trial participants

OBJECTIVES

To determine the variation in the time from onset of symptoms to clinical presentation (time to presentation [TTP]) in a cohort of sexual health attendees with symptomatic uncomplicated genital gonorrhoea and to identify factors associated with TTP.

METHODS

Participants were recruited from 14 clinics across England into the 'Gentamicin for the Treatment of Gonorrhoea (GToG)' trial between October 2014 and November 2016. Multivariable analysis was performed using prospectively collected demographic, behavioural and clinical data in a subset of the GToG study cohort presenting with genital discharge and/or dysuria who tested positive for Neisseria gonorrhoeae using a nucleic acid amplification test. The results were expressed as geometric mean ratios (GMR) with 95% CI for time to presentation after onset of symptoms.

RESULTS

316 participants (269 men and 47 women) with a median age of 27.6 years (IQR 23.0-34.8) were included. 194 (61%) were Caucasian, 29 (9%) Black African, 27 (9%) Asian and 66 (21%) of other ethnicities. Median TTP was 3 days for men (IQR 2-7) and 14 days for women (IQR 7-21). Participants reported genital discharge (297/316 [94%]), dysuria (251/316 [79%]), both genital discharge and dysuria (232/316 [73%]) and other concurrent symptoms 76/316 (24%) (e.g., rectal bleeding or genital itching). 45/316 (14%) participants reported sexual contact while symptomatic, of whom TTP was more than 7 days in 32/45 (71%). A longer TTP was associated with gender (female cf. male, GMR 2.34 [1.67 to 3.26]), no prior history of gonorrhoea (GMR 1.46 [1.15 to 1.86]), 'regular' or 'ex-regular' sexual relationship (regular cf. one off GMR 1.35 [1.05 to 1.72]); ex-regular cf. one off GMR 1.88 [1.12 to 3.14]), and being heterosexual (GMR 1.69 [1.31 to 2.19]).

CONCLUSION

Specific demographic and behavioural factors are associated with a longer TTP in individuals with symptomatic genital gonorrhoea. Detailed knowledge of these factors can be used to prioritise and optimise gonorrhoea management and prevention.

"Putting people in charge of their own health and care?" Using meta-narrative review and the example of online sexual health services to re-think relationships between e-health and agency

INTRODUCTION

Policy discussions reference ideas of informed and active users of e-health services who gain agency through self-management, choice and care delivered outside clinical settings. In this article, we aim to problematize this association by "thinking with" material from multiple disciplines to generate higher order insights to inform service development, research and policy.

METHODS

Drawing on meta-narrative review methods, we gathered perspectives from multiple disciplines using an iterative process of expert consultation to identify seminal papers citation mapping, synthesis and peer review.

RESULTS

We identify six relevant paradigms from sociology, philosophy, health services research, public health, the study of social movements and computer studies. Bringing these paradigms together illuminates the contrasting epistemological and ontological framings that co-exist in this area, including competing conceptualizations of e-health technologies as: neutral tools for service delivery, mediators within complex and unpredictable clinical interactions and as agents in their own right.

DISCUSSION

There is a need for e-health policy to recognize many human and non-human actors, the blurred boundaries between them and the unpredictable and evolving interactions that constitute engagement with e-health care. Established models for e-health service development and policy making are not designed for this landscape. There is nothing to be gained by asking whether e-health, in general, either "increases" or "decreases" agency. Rather specific types and aspects of e-health have diverse effects and can be simultaneously enabling and disempowering, and be differentially experienced by differently positioned and resourced actors.

Understanding the attitudes and acceptability of extra-genital Chlamydia testing in young women: evaluation of a feasibility study

BACKGROUND

Chlamydia trachomatis (C. trachomatis) is the most common bacterial sexually transmitted infection in the UK. Recent studies suggest that in addition to the genital tract, C. trachomatis is found in the throat and rectum, suggesting the number of infections is under-reported. There is an urgent need to study the impact of extending diagnosis to include extra-genital samples; however, there is a lack of evidence on the acceptability of asking young women to provide these samples.

METHOD

A mixed methods single group feasibility study explored the acceptability of combined genital and extra-genital testing in young women aged 16-25 years consecutively attending a sexual health centre in Edinburgh, Scotland. Young women were asked to complete a self- administered anonymous questionnaire whether they would be willing to give self-taken throat and ano-rectal samples. Interviews with women (n = 20) willing to self-sample were conducted before and after self-sampling, and these explored the underlying reasons behind their decision, and feelings about the tests.

RESULTS

Of 500 women recruited to the study, 422 (84.4%) women provided sufficient data for analysis. From completed questionnaires, 86.3% of respondents reported willingness to self-sample from the throat. Willingness of ano-rectal self-sampling was lower (59.1%), particularly in women under 20 (< 20 years: 44.4%; ≥20 years, 68.2%). Willingness of ano-rectal self-sampling was higher in women who had more sexual partners in the last 6 months (0 partners, 48.3%, n = 14, 3 or more partners, 67.4%, n = 60) and in those who have previous experience of a positive test for a sexually transmitted infection (STI) (positive: 64.5%; negative: 57%). Interviewed women suggested that a lack of knowledge of STIs, embarrassment and lack of confidence in the ability to carry out the sampling were barriers towards acceptability.

CONCLUSIONS

In this study, self-sampling of throat samples is largely acceptable; however, the acceptability of taking an ano-rectal sample for C. trachomatis testing in young women was lower in younger women. The study suggests further research to investigate the acceptability of extra-genital testing as an addition to routine C. trachomatis testing, and whether this increases detection and prevents infective sequelae for women.

Evaluation of the 'Colli-Pee', a first-void urine collection device for self-sampling at home for the detection of sexually transmitted infections, versus a routine clinic-based urine collection in a one-to-one comparison study design: efficacy and acceptability among MSM in Belgium

OBJECTIVES

Pre-exposure prophylaxis (PrEP) users are screened bi-annual for sexually transmitted infections (STIs). A novel device, called the Colli-Pee, collects first-void urine in a standardised way and the collector tube can be easily delivered by regular post to a certified laboratory. The aim of the study was a one-to-one comparison between the STI test results obtained with the urine collected in the clinic, versus urine collected at home in a real-life setting by Men who have Sex with Men (MSM) in Belgium. The user-friendliness and acceptability of the Colli-Pee device by the users was also evaluated.

DESIGN

A single-site nested substudy in a prospective PrEP demonstration project (Be-PrEP-ared) among MSM in Belgium.

PARTICIPANTS

A total of 473 home-based samples from 213 MSM were received with a mean age of 38.5 years.

INTERVENTIONS

Participants were requested to collect a urine sample at home using the Colli-Pee device and to send it to the laboratory via regular mail.

PRIMARY AND SECONDARY OUTCOME MEASURES

The presence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) was determined using molecular amplification assays. Agreement between test results of samples collected at the clinic and collected at home were evaluated using Cohen's kappa statistic.

RESULTS

TV was not detected. A very good to almost perfect agreement was found for CT, NG and MG of κ=0.75, 0.87 and 0.85, respectively. Using the Colli-Pee device only one low positive CT and two MG infections were missed, however, three additional CT, two NG and six MG infections were detected.

CONCLUSIONS

The Colli-Pee device is a feasible and convenient way to collect urine at home for STI testing. This may be particularly relevant for populations that need frequent STI testing, such as PrEP users and patients who prefer home-sampling.

TRIAL REGISTRATION NUMBER

NCT02552914; Pre-results.