Internet-Based Testing for STIs Increase Uptake

Providing internet-based testing for sexually transmitted infections (e-STI testing) could increase the number of people being tested for syphilis, HIV, chlamydia, and gonorrhoea, including among high-risk groups, according to a study published Dec. 27, 2017 in PLOS Medicine. e-STI testing doubled testing uptake compared to testing uptake among participants randomized to testing at usual care health clinics.

The World Health Organization says that increasing testing, diagnosis, and treatment of STIs and reducing time to treatment is a global priority to reduce the prevalence of STIs and their downstream consequences. In the United Kingdom, like in the United States, STI testing levels remains sub-optimal.

FDA Weighs Self-Sampling for Pap Testing

In early January a U.S. Food and Drug Administration (FDA) expert panel met to address the feasibility, benefits and risks of self-collection cervical sampling for cervical cancer screening by Pap testing. Speakers were split on whether the benefits of self-sampling, primarily increasing access to testing particularly among underserved populations, outweighed the risks posed by accuracy concerns and uncertain standards for follow-up on abnormal results.

The U.S. Centers for Disease Control and Prevention presented data showing that screening levels have remained stable since 2000 (about 80 percent) and that certain populations remain underscreened (e.g., women with lower educations, underinsured, and those from certain ethnicities and geographical regions).

The panel seemed to agree that any self-collection devices for Pap testing must be held to the same standards necessary for current clinic-performed Pap testing. Yet, there was not agreement on the design of studies to assess the performance of self-selection against current standards of care. Other unresolved issues included whether laboratories should report these results directly to patients and how those with abnormal results could be linked to follow-up care.

Shyam Kalavar, a scientific reviewer with the FDA's Office of In Vitro Diagnostics and Radiological Health, told Medscape that although the meeting was focused on self-collection for liquid-based Pap testing, it could lay the groundwork for how the agency might approach other self-collection devices for cervical cancer screening.

Interventions, like e-STI, that increase access, particularly among high-risk and hard-to-reach groups, are of high interest to maximize the public health benefits of STI testing, while offering patient benefits such as increasing convenience and removing embarrassment associated with face-to-face STI services. e-STI testing typically enables users to order a test kit from a website or app, collect their own samples, mail test samples to a laboratory, and receive results electronically.

In the U.K.-based study, 2,072 sexually active young people (aged 16 to 30 years of age residing in two London boroughs), with stated willingness to take an STI test, were randomized to receive a text message. The text message provided either the website for eSTI or the location of a local STI health clinic. Randomization balanced gender (male, female, transgender), age (16 to 19 years, 20 to 24 years, and 25 to 30 years), number of sexual partners in last 12 months, and sexual orientation. If participants reported using another health service outside of the study providers during the study period, STI testing, diagnosis, and treatment data was collected.

The e-STI program, SH:24, offers free postal self-sampling test kits for chlamydia, gonorrhoea, HIV, and syphilis. All test kits contained a lancet and collection tube to obtain a blood sample for serological testing for syphilis and HIV, as well as either a vaginal swab (women) or urine collection (men) for chlamydia and gonorrhea. For men who have sex with men (MSM), test kits also contained swabs to take pharyngeal and rectal samples. The tests kits included pictorial brochures with instructions for sample collection and a Youtube blood sample collection video on SH:24 website. After 2 weeks, non-returners were sent reminders via text and resent test kits, if required. Chlamydia, gonorrhoea, and syphilis results were returned by text message, while positive HIV results were returned by phone. Confirmatory testing and treatment were provided at local clinics.

The researchers found that at 6 weeks, significantly more participants in the intervention group completed an STI test compared to the control group (50 percent versus 26.6 percent). However, there were no significant differences in the number diagnosed nor the time to treatment.

"The long-term public health benefits of e-STI services will depend on testing, diagnosis, and treatment rates when implemented. These outcomes should be subject to ongoing monitoring and evaluation," write the authors led by Emma Wilson, from the London School of Hygiene & Tropical Medicine in the United Kingdom. The authors add in a statement that, "going forward we advise joint commissioning of these different modalities of care to ensure that users are able to move easily from one to another according to their health care needs, allowing continuity of care."

Takeaway: e-STI may increase testing uptake, including upon high-risk populations.