[00.00] Introduction
Hello everyone. My name is Meena Ramchandani. I’m an infectious disease physician at the University of Washington in Seattle. This podcast is dedicated to an STD [sexually transmitted disease] literature review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs.

[00.23] Background
Due to the COVID-19 pandemic, the world and our interactions are a bit different now—to put things mildly. Many clinics have been closed or are slowly reopening for patient care, per the recommended local guidelines. In the Sexual Health Clinic for Seattle and King County, we had to quickly initiate telemedicine and telephone visits in place of clinic visits when COVID-19 first hit, and delay patient visits for the safety of both patients and staff. I decided to focus this podcast on home-based STD testing and picked out a few articles on this topic published in the last five years. The reason this came up is that we have more than 600 clients enrolled in our PrEP [preexposure prophylaxis] program within the clinic, and home-based testing may be one way to achieve asymptomatic STD and HIV screening during this difficult time. Studies have shown that home-based STD testing can potentially help decrease cost, as well as stigma in accessing STD services, and they might be more convenient for patients overall. There are enough data to support the acceptability, feasibility, and accuracy of self-collected samples for STD testing, which I will not go into today. The focus of this podcast is to review some relevant articles in the literature on home-based STD testing for asymptomatic individuals.

[01.43] Paper #1
Fisher M, Wayal S, Smith H, Llewellyn C, Alexander S, Ison C, Parry JV, Singleton G, Perry N, Richardson D; Brighton Home Sampling Kit Project Steering Group. Home sampling for sexually transmitted infections and HIV in men who have sex with men: A prospective observational study. PLoS One. 2015 Apr 7;10(4):e0120810.
[PubMed Abstract]

The first article I’d like to introduce is titled “Home sampling for sexually transmitted infections and HIV in men who have sex with men: A prospective observational study,” by Dr. Martin Fisher and colleagues. The study was done at three facilities providing STI and HIV testing in Brighton, United Kingdom (UK). This study was published in PLOS ONE in 2015, but of note, was conducted in 2008. So, interesting features of this study:

There were three different participant groups enrolled. The first participant group included adult MSM [men who have sex with men] contacting or attending a sexual health clinic requesting STI testing. (They call sexual health clinics Genitourinary Medicine Services in the United Kingdom—just as an FYI.) The second group were MSM with HIV who were attending a routine clinic visit as part of their HIV primary care. And the third group were MSM attending a community-based rapid HIV testing service. All participants were offered a home sampling kit for STD testing, as well as HIV testing versus in-person, clinic-based testing. But doing the home-based testing, the participants actually needed to return the specimens in person to the sexual health clinic or the HIV clinic. And this is important to remark on because the patients couldn’t just send the test kits in via the mail. They actually had to physically go into the clinic to return the test kits.
The home sampling kits included the following: swabs and a urine container to collect specimens for chlamydia and gonorrhea testing, as well as a swab to collect saliva specimens for HIV antibody (if negative) and a syphilis treponemal antibody testing as well. No blood test was done in this study.
What doctors found is that, overall, 75% of individuals at the three sites opted for home-based testing over clinic-based testing. So, it was favorably accepted.
Among all the home sampling kits given out, 47% were returned, but there was a difference in the return rate by study site. For example, the return rate was 78% amongst those attending the sexual health clinic, but only 16% amongst participants from the community-based testing services.
In looking more closely at the individuals who returned the home testing kits, they had an overall median age that was in the 30s-40s range, and 30-50% had higher levels of education.
The authors found that the overall STI incidence was 13% among the home testing kits returned, including 9% for chlamydia, 2.5% for gonorrhea, and 1.5% for newly diagnosed syphilis—these rates were similar for each recruiting site, and were comparable to the rates seen in asymptomatic MSM undergoing STI testing in the sexual health clinic. No new HIV diagnoses were made but the authors do point out that the duration of the study was only about seven months.

Overall, this study does suggest that home-based testing is acceptable to MSM and might be a really good alternative to clinic-based testing for STDs and HIV. I’d love to see this study repeated now that PrEP is widely available, and home testing kits could also include self-collection blood sampling for fourth-generation HIV antigen-antibody tests; it would also be good to include syphilis testing, especially one that had an RPR option for those with a history of syphilis. Last, since we now get packages so easily—yesterday I ordered something online and today it was delivered at my door—it would be great if home-based testing included home delivery of testing kits and test results given online or through text message, or some sort of tech format, to make this whole process a lot more convenient for clients. It would also be great if clients could send in the home testing kits back to the clinic via the mail. This study reported that treatment for patients with positive test results was performed per standard clinic protocols, but it would be really interesting to know more details about treatment.

[05.43] Paper #2
Manavi K, Hodson J. Observational study of factors associated with return of home sampling kits for sexually transmitted infections requested online in the UK. BMJ Open. 2017 Oct 22;7(10):e017978.
[PubMed Abstract]

The next article I’d like to discuss is titled “Observational study of factors associated with return of home sampling kits for sexually transmitted infections requested online in the United Kingdom,” by Dr. Kaveh Manavi and Dr. James Hodson, published in the British Medical Journal in 2017. The key features of this study:

Participants in this study could request STD and HIV kits on a website without the need for a referral from their general practitioner. The kits were delivered, per patient preference, to the participant’s home or to a pharmacy or sexual health clinic nearby where they live. The goal was to screen asymptomatic patients.
Kits included swabs and urine containers to test for chlamydia and gonorrhea, and actually had a finger-prick device to obtain blood samples for HIV and syphilis serology testing. Of note, the testing for syphilis was still a treponemal antibody test so it only would be helpful in those without a history of syphilis.
They actually found that about 5,300 kits were requested. Both men and women were included in the study.
Of these 5,300 kits, only 58% of kits were returned. And on multivariate analysis, the rates of return were similar for both women and MSM, but they found that the STD kits from heterosexual males were less likely to be returned. Kits that were delivered to a patient’s home, rather than a clinic or a pharmacy, were more likely to be returned, and that had a significant Pvalue of less than .001 (p<0.001).

The aim of this study was to investigate the rate of return for home sampling kits and features of participants that were more likely to return the kits. The return rate of 58% seems to be similar to other studies looking at home-based STD or HIV testing kits. What I like about this program is that patients were informed of their test results by text messaging within one hour of results being available. Although patients were informed of their test results, it’s not clear how many were treated if diagnosed with an STD and in what timeframe. The home STD testing service is part of the Umbrella Health, which is a free sexual health service in parts of the United Kingdom that has implemented innovative and very convenient ways to test and treat clients with STDs and HIV. I’d be curious to hear more about the management of STDs and HIV in these home testing programs.

[08.12] Paper #3
Hogenson E, Jett-Goheen M, Gaydos CA. An analysis of user survey data for an internet program for testing for sexually transmitted infections, I Want the Kit, in Maryland and Washington, DC. Sex Transm Dis. 2019 Dec;46(12):768-770.
[PubMed Abstract]

The third article to discuss today is titled “An analysis of user survey data for an internet program for testing for sexually transmitted infections, I Want the Kit, in Maryland and Washington, DC,” by Dr. Hogenson and colleagues published in Sexually Transmitted Diseases in December 2019. This manuscript describes survey results for the “I Want the Kit” program that offers home-based STD testing for chlamydia, gonorrhea, and trichomonas. The program was initially designed for women, but it has expanded to include STD testing for men, as well. The study utilized an online format for individuals to order kits and to obtain their own results. In this program, clients ordered the kit online, received the kit by mail, collected their own samples, checked their results online when notified, and completed a survey about the process. So, interesting features about this article:

The survey wanted to evaluate user acceptability for the program and explore future directions.
They had 457 respondents and 62% were female. Three participants were gender queer and one participant was trans male. The participants were from a diverse group of ethnicities with most being in the age range of 20-40 years old.
The authors found that 62% of respondents stated that home was the preferred place of testing for STDs and more than 90% said self-swabs were “easy” or “very easy” to use. Greater than 90% felt it was “easy” or “very easy” to order the kits and understand the collection instructions.
The average cost respondents would be willing to pay for an in-home rapid test device, if available, was approximately 20 U.S. dollars and most participants were willing to self-collect for blood samples, if needed.

It seems as though, in this program, participants were satisfied with the home STD testing kit model, and 62% said home was the preferred place for STD testing; while this is the majority of participants, it also suggests that giving options to clients might be needed for more widespread STD testing.

[10.23] Summary
These three articles contribute to our understanding of home-based testing and reinforce the need for novel approaches to increase STD and HIV testing in general. Home testing may be one way to meet this need and can potentially address some of the barriers to clinic-based STD testing. These might include stigma, privacy, and confidentiality concerns, for example; or even difficulties with transportation, or time constraints. Home testing can also help offload some of the clinic burden for routine STD testing that may tax clinic capacity. Some of the issues that arise are turnaround time for test results, how to give clients their test results, and implementing further management and follow-up, such as treatment for an STD and treatment for partners.

I encourage you to take a look at these articles as they might help in understanding what might be feasible for your practice. Two other articles that I would like to point out that were helpful on this topic and encourage you to read if interested: "Developing and assessing the feasibility of a home-based preexposure prophylaxis monitoring and support program," by Dr. Siegler and colleagues in Clinical Infectious Diseases, published in February 2019, and “Acceptability and feasibility of self-collecting biological specimens for HIV, sexually transmitted infection, and adherence testing among high-risk populations,” by Dr. Sharma and colleagues, published in the Journal of Medical Internet Research in 2019. So, we’re just experimenting with home-based STI and HIV testing in our clinic and will soon incorporate home-based testing kits for some of our PrEP patients who are asymptomatic and need regular screening. One of our colleagues is also doing a research study on this topic, Dr. Chase Cannon, so stay tuned for the results of his work.

To conclude, I’d like to summarize some key points from this session:

Home-based STD and HIV testing is a promising tool to increase testing of individuals at risk of acquiring STDs and HIV, and can be integrated in clinical practice and PrEP care for asymptomatic individuals.
Home testing may help to decrease stigma and alleviate some of the structural barriers to STI and HIV testing in certain patients.
Using technology to help with ordering samples and obtaining results is useful for increasing engagement in the home testing process.
Lastly, follow up of home testing results needs to be integrated into the clinical practice so that patients and their partners can get treated, and I really look forward to hearing more on treatment management of those with STDs who undergo home-based STD testing.

[12.52] Credits
This podcast is brought to you by the National STD Curriculum, the University of Washington STD Prevention Training Center, and is funded by the Centers for Disease Control and Prevention.

Transcripts and references for this podcast series can be found on our website, the National STD Curriculum at www.std.uw.edu. Thank you for listening.

Additional References
Siegler AJ, Mayer KH, Liu AY, Patel RR, Ahlschlager LM, Kraft CS, Fish R, Wiatrek SE, Sullivan PS. Developing and assessing the feasibility of a home-based preexposure prophylaxis monitoring and support program. Clin Infect Dis. 2019 Jan 18;68(3):501-504. [PubMed Abstract].

Sharma A, Stephenson R, Sallabank G, Merrill L, Sullivan S, Gandhi M. Acceptability and feasibility of self-collecting biological specimens for HIV, sexually transmitted infection, and adherence testing among high-risk populations (Project Caboodle!): Protocol for an exploratory mixed-methods study. JMIR Res Protoc. 2019 May 2;8(5):e13647.[PubMed Abstract]