Date Published: December 27, 2017
Publisher: Public Library of Science
Author(s): Emma Wilson, Caroline Free, Tim P. Morris, Jonathan Syred, Irrfan Ahamed, Anatole S. Menon-Johansson, Melissa J. Palmer, Sharmani Barnard, Emma Rezel, Paula Baraitser, Nathalie Broutet
Abstract: BackgroundInternet-accessed sexually transmitted infection testing (e-STI testing) is increasingly available as an alternative to testing in clinics. Typically this testing modality enables users to order a test kit from a virtual service (via a website or app), collect their own samples, return test samples to a laboratory, and be notified of their results by short message service (SMS) or telephone. e-STI testing is assumed to increase access to testing in comparison with face-to-face services, but the evidence is unclear. We conducted a randomised controlled trial to assess the effectiveness of an e-STI testing and results service (chlamydia, gonorrhoea, HIV, and syphilis) on STI testing uptake and STI cases diagnosed.Methods and findingsThe study took place in the London boroughs of Lambeth and Southwark. Between 24 November 2014 and 31 August 2015, we recruited 2,072 participants, aged 16–30 years, who were resident in these boroughs, had at least 1 sexual partner in the last 12 months, stated willingness to take an STI test, and had access to the internet. Those unable to provide consent and unable to read English were excluded. Participants were randomly allocated to receive 1 text message with the web link of an e-STI testing and results service (intervention group) or to receive 1 text message with the web link of a bespoke website listing the locations, contact details, and websites of 7 local sexual health clinics (control group). Participants were free to use any other services or interventions during the study period. The primary outcomes were self-reported STI testing at 6 weeks, verified by patient record checks, and self-reported STI diagnosis at 6 weeks, verified by patient record checks. Secondary outcomes were the proportion of participants prescribed treatment for an STI, time from randomisation to completion of an STI test, and time from randomisation to treatment of an STI. Participants were sent a £10 cash incentive on submission of self-reported data. We completed all follow-up, including patient record checks, by 17 June 2016. Uptake of STI testing was increased in the intervention group at 6 weeks (50.0% versus 26.6%, relative risk [RR] 1.87, 95% CI 1.63 to 2.15, P < 0.001). The proportion of participants diagnosed was 2.8% in the intervention group versus 1.4% in the control group (RR 2.10, 95% CI 0.94 to 4.70, P = 0.079). No evidence of heterogeneity was observed for any of the pre-specified subgroup analyses. The proportion of participants treated was 1.1% in the intervention group versus 0.7% in the control group (RR 1.72, 95% CI 0.71 to 4.16, P = 0.231). Time to test, was shorter in the intervention group compared to the control group (28.8 days versus 36.5 days, P < 0.001, test for difference in restricted mean survival time [RMST]), but no differences were observed for time to treatment (83.2 days versus 83.5 days, P = 0.51, test for difference in RMST). We were unable to recruit the planned 3,000 participants and therefore lacked power for the analyses of STI diagnoses and STI cases treated.ConclusionsThe e-STI testing service increased uptake of STI testing for all groups including high-risk groups. The intervention required people to attend clinic for treatment and did not reduce time to treatment. Service innovations to improve treatment rates for those diagnosed online are required and could include e-treatment and postal treatment services. e-STI testing services require long-term monitoring and evaluation.Trial registrationISRCTN Registry ISRCTN13354298.
Partial Text: Sexually transmitted infections (STIs) continue to be a global public health concern, with an estimated 357 million new infections of curable STIs (chlamydia, gonorrhoea, syphilis, and trichomoniasis) each year . In England, there were 436,928 new diagnoses of STIs and 5,684 new cases of HIV in 2015 [2,3]. The burden of infection is disproportionately high among young adults (under 25 years), men who have sex with men (MSM), and black and minority ethnic (BME) groups .
We carried out a single-blind randomised controlled trial of an e-STI testing and results service. The trial was conducted in London, UK, and participants were recruited between 24 November 2014 and 31 August 2015. Ethical approval was obtained from the National Research Ethics Service (NRES) Committee London–Camberwell St Giles (Ref 14/LO/1477). The trial protocol was accepted for publication in April 2015 and was published in January 2016 [27,28].
In all, 2,072 participants were randomly assigned to the SH:24 online testing and results service or to the control group (Fig 1). We excluded 8 participants who were randomised twice and 1 participant who was randomised and did not meet the age criterion (Fig 1). We were unable recruit to target, and therefore we lacked power for the co-primary outcome of STI diagnoses. Baseline characteristics are presented in Table 1.
We trialled SH:24 in a community setting, in 2 boroughs well served by face-to-face clinical services. Providing e-STI testing in contexts where supply is more limited, or targeting particular high-risk groups, might strengthen the contribution of e-STI testing to the control and management of STIs.