STI Testing: At-Home Edition
Sexually transmitted infections (STIs) are a major source of infectious disease in the UK, with over 420,000 people diagnosed with an STI in 2017 [1]. Despite reports of extensively-drug resistant Neisseria gonorrhoea in the UK coupled with increased attendance at sexual health clinics, large spending cuts have been made to sexual health services (SHS) nationwide. This has led to me being concerned about what this means for the control of STIs in the UK, so I thought I would research test-at-home STI kits, one of the steps the NHS is taking to save resources and improve access.
Test-at-home STI kits instead of routine testing services are one way to save money during SHS cuts, freeing up resources in clinics and providing broader access to those who find themselves travelling a long distance to a clinic. In theory, this allows for people with limited access to urban centres (where clinics are typically based) and those in remote villages with poor public transport to access SHS. Additionally, those who may be unable to attend a clinic for fear of judgement or shame may be more willing to complete a test kit in the privacy of their home, where they don’t have to answer questions from a stranger about their sex life.
I, however, have some concerns about this scheme. The time scales involved to get test results can be relatively long; it can take almost 3 weeks for the results to come back from ordering the kit to the results being processed, assuming you do the tests and post the kit back on the day you get it. This is a long time in the world of STIs! Not only could a person have several new partners in this time, transferring potential infections, but many STIs can get significantly worse over a short period of time. In 3 weeks, HIV can change from ‘take a couple of tablets and you should be fine’ to ‘you need to take medication for life’ to manage the disease and the discrimination faced by HIV-positive people. Another concern of mine is that the lack of face-to-face conversation could cause risk factors or abusive situations to be missed. In person, body language cues and demeanour can be observed by a healthcare professional to judge if the patient may be hiding something.
To find out more about these kits, I decided to order one and see what the experience was like. So, I went to the iCaSH Norfolk website, which is my local SHS, and couldn’t miss the massive ‘ORDER YOUR SELF TEST KIT TODAY’ button at the top of each page. Clicking this link prompts you to create an account, where you are asked a few questions about yourself and your sex life. This is where my first concern was realised. On my local SHS website, there is no information about how you will be contacted with results, nor anything concerning the packaging the test will be delivered in. I understand that this is a problem that some other SHS providers may not have, but this lack of reassurance about being discrete may discourage victims of domestic abuse, who could be put at risk, or teenagers living at home who do not want to involve their parents.
After creating my account, the full questionnaire began. First, I was asked if I was showing symptoms of an STI or had had unprotected sex in the past 5 days. Answering yes to either of these questions prompted a warning message telling me I needed to attend a clinic but did not stop me from carrying on the questionnaire and ordering the kit. I was then asked If I have experienced domestic or sexual abuse. The answer to this was a tick in either a yes or no checkbox. In my opinion, this is an inadequate way of identifying those in abusive situations, who may be unwilling to answer yes to this question. I am also asked if I ‘take alcohol or drugs’, again with yes or no answer options. I find this to be a wholly ineffective question; drinking a beer on a Friday is unlikely to contribute to your risk of getting an STI, whereas being a regular IV drug user puts you at a much higher risk of exposure.
Next, comes a short series of risk factor questions such as if I have paid for sex and have I had sex with somebody from Africa? Unfortunately, there were a lot of missing questions which should have been asked but were not. For example, I was not asked if I have oral, vaginal or anal sex with my partners, which would inform where I needed to be tested for infections. I was also not asked about how many sexual partners I had since my last test, nor if I had chemsex, all questions that I would be asked in a clinic. After completing my questionnaire, I was told what tests they would conduct and to expect my kit to arrive soon. Only after ordering the test you are finally informed that it will be delivered in discrete packaging.
Once the kit arrived, it was straightforward with lots of clear pictures about where to stick the swabs and how much pee they needed. I did find up getting enough blood impossible though and gave up after much pain and time yielded a fraction of the several millilitres of blood required. Speaking to friends, I was reassured that I’m not the only one who skips the blood tests. Results did come back very quickly after I posted my kit, in 3 or 4 days, all clear there thankfully!
After completing my kit, I thought I’d check to see how that experience compared to London Sexual Health (LSH). Their triage questions were much more comprehensive than the ones I was asked previously, covering recreational drug use, pre-exposure prophylaxis and Hepatitis vaccinations. I have been asked by the spokesperson at LSH to point out that LSH is a new, innovative service running under a unique model, so it isn’t fair to compare this to Norfolk’s SHS provider.
Overall, after using a test-at-home kit myself, I think they are a good idea that is implemented well in most areas. In my opinion, triage could be improved, as could signposting on where to go if you have STI symptoms, or simply want some condoms. I would also be wary of how these kits are used by people. They are intended to be used as regular check-ups rather than replacing a full assessment offered at a clinic, but at least one of my friends has used these kits exclusively and never attended a clinic despite sleeping with over 30 unique partners between tests. They saw no issue with just using one of these kits every couple of months, whereas I would suggest they should have attended a clinic for a more thorough check-up.
Regardless of my thoughts, the kits are popular both with users and a stretched health service. They offer a cheaper method of routine testing, can help improve access in rural areas and provide a certain amount of privacy to otherwise reluctant users.
Further reading
[1] https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables