J Gibbs

The eSexual Health Clinic system for management, prevention, and control of sexually transmitted infections: exploratory studies in people testing for Chlamydia trachomatis

BACKGROUND Self-directed and internet-based care are key elements of eHealth agendas. We developed a complex online clinical and public health intervention, the eSexual Health Clinic (eSHC), in which patients with genital chlamydia are diagnosed and medically managed via an automated online clinical consultation, leading to antibiotic collection from a pharmacy. Partner notification, health promotion, and capture of surveillance data are integral aspects of the eSHC. We aimed to assess the safety and feasibility of the eSHC as an alternative to routine care in non-randomised, exploratory proof-of-concept studies. METHODS Participants were untreated patients with chlamydia from genitourinary medicine clinics, untreated patients with chlamydia from six areas in England in the National Chlamydia Screening Programmes (NCSP) online postal testing service, or patients without chlamydia tested in the same six NCSP areas. All participants were aged 16 years or older. The primary outcome was the proportion of patients with chlamydia who consented to the online chlamydia pathway who then received appropriate clinical management either exclusively through online treatment or via a combination of online management and face-to-face care. We captured adverse treatment outcomes. FINDINGS Between July 21, 2014, and March 13, 2015, 2340 people used the eSHC. Of 197 eligible patients from genitourinary medicine clinics, 161 accessed results online. Of the 116 who consented to be included in the study, 112 (97%, 95% CI 91-99) received treatment, and 74 of those were treated exclusively online. Of the 146 eligible NCSP patients, 134 accessed their results online, and 105 consented to be included. 93 (89%, 95% CI 81-94) received treatment, and 60 were treated exclusively online. In both groups, median time to collection of treatment was within 1 day of receiving their diagnosis. 1776 (89%) of 1936 NCSP patients without chlamydia accessed results online. No adverse events were recorded. INTERPRETATION The eSHC is safe and feasible for management of patients with chlamydia, with preliminary evidence of similar treatment outcomes to those in traditional services. This innovative model could help to address growing clinical and public health needs. A definitive trial is needed to assess the efficacy, cost-effectiveness, and public health impact of this intervention. FUNDING UK Clinical Research Collaboration.

‘Can you recommend any good STI apps?’ A review of content, accuracy and comprehensiveness of current mobile medical applications for STIs and related genital infections

Objective Seeking sexual health information online is common, and provision of mobile medical applications (apps) for STIs is increasing. Young people, inherently at higher risk of STIs, are avid users of technology, and apps could be appealing sources of information. We undertook a comprehensive review of content and accuracy of apps for people seeking information about STIs. Methods Search of Google Play and iTunes stores using general and specific search terms for apps regarding STIs and genital infections (except HIV), testing, diagnosis and management, 10 September 2014 to 16 September 2014. We assessed eligible apps against (1) 19 modified Health on The Net (HON) Foundation principles; and (2) comprehensiveness and accuracy of information on STIs/genital infections, and their diagnosis and management, compared with corresponding National Health Service STI information webpage content. Results 144/6642 apps were eligible. 57 were excluded after downloading. 87 were analysed. Only 29% of apps met ≥6 HON criteria. Content was highly variable: 34/87 (39%) covered one or two infections; 40 (46%) covered multiple STIs; 5 (6%) focused on accessing STI testing. 13 (15%) were fully, 46 (53%) mostly and 28 (32%) partially accurate. 25 (29%) contained ≥1 piece of potentially harmful information. Apps available on both iOS and Android were more accurate than single-platform apps. Only one app provided fully accurate and comprehensive information on chlamydia. Conclusions Marked variation in content, quality and accuracy of available apps combined with the nearly one-third containing potentially harmful information risks undermining potential benefits of an e-Health approach to sexual health and well-being.

The eClinical Care Pathway Framework: a novel structure for creation of online complex clinical care pathways and its application in the management of sexually transmitted infections.

BackgroundDespite considerable international eHealth impetus, there is no guidance on the development of online clinical care pathways. Advances in diagnostics now enable self-testing with home diagnosis, to which comprehensive online clinical care could be linked, facilitating completely self-directed, remote care. We describe a new framework for developing complex online clinical care pathways and its application to clinical management of people with genital chlamydia infection, the commonest sexually transmitted infection (STI) in England.MethodsUsing the existing evidence-base, guidelines and examples from contemporary clinical practice, we developed the eClinical Care Pathway Framework, a nine-step iterative process. Step 1: define the aims of the online pathway; Step 2: define the functional units; Step 3: draft the clinical consultation; Step 4: expert review; Step 5: cognitive testing; Step 6: user-centred interface testing; Step 7: specification development; Step 8: software testing, usability testing and further comprehension testing; Step 9: piloting. We then applied the Framework to create a chlamydia online clinical care pathway (Online Chlamydia Pathway).ResultsUse of the Framework elucidated content and structure of the care pathway and identified the need for significant changes in sequences of care (Traditional: history, diagnosis, information versus Online: diagnosis, information, history) and prescribing safety assessment. The Framework met the needs of complex STI management and enabled development of a multi-faceted, fully-automated consultation.ConclusionThe Framework provides a comprehensive structure on which complex online care pathways such as those needed for STI management, which involve clinical services, public health surveillance functions and third party (sexual partner) management, can be developed to meet national clinical and public health standards. The Online Chlamydia Pathway’s standardised method of collecting data on demographics and sexual behaviour, with potential for interoperability with surveillance systems, could be a powerful tool for public health and clinical management.

Can Remote STI/HIV Testing and eClinical Care be Compatible with Robust Public Health Surveillance?

In this paper we outline the current data capture systems for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) surveillance used by Public Health England (PHE), and how these will be affected by the introduction of novel testing platforms and changing patient pathways. We outline the Chlamydia Online Clinical Care Pathway (COCCP), developed as part of the Electronic Self-Testing for Sexually Transmitted Infections (eSTI2) Consortium, which ensures that surveillance data continue to be routinely collected and transmitted to PHE. We conclude that both novel diagnostic testing platforms and established data capture systems must be adaptable to ensure continued robust public health surveillance.

Are HIV Smartphone Apps and Online Interventions Fit for Purpose

Sexual health is an under-explored area of Human-Computer Interaction (HCI), particularly sexually transmitted infections such as HIV. Due to the stigma associated with these infections, people are often motivated to seek information online. With the rise of smartphone and web apps, there is enormous potential for technology to provide easily accessible information and resources. However, using online information raises important concerns about the trustworthiness of these resources and whether they are fit for purpose. We conducted a review of smartphone and web apps to investigate the landscape of currently available online apps and whether they meet the diverse needs of people seeking information on HIV online. Our functionality review revealed that existing technology interventions have a one-size-fits-all approach and do not support the breadth and complexity of HIV-related support needs. We argue that technology-based interventions need to signpost their offering and provide tailored support for different stages of HIV, including prevention, testing, diagnosis and management.

Using the eSexual Health Clinic to access chlamydia treatment and care via the internet: a qualitative interview study.

Objective We developed the eSexual Health Clinic (eSHC), an innovative, complex clinical and public health intervention, embedded within a specialist sexual health service. Patients with genital chlamydia access their results online and are offered medical management via an automated online clinical consultation, leading to antibiotic collection from community pharmacy. A telephone helpline, staffed by Sexual Health Advisers, is available to support patients and direct them to conventional services if appropriate. We sought to understand how patients used this ehealth intervention. Methods Within exploratory studies of the eSHC (2014–2015), we conducted in-depth interviews with a purposive sample of 36 patients diagnosed with chlamydia, who had chosen to use the eSHC (age 18–35, 20 female, 16 male). Thematic analysis was conducted. Results Participants described choosing to use this ehealth intervention to obtain treatment rapidly, conveniently and privately, within busy lifestyles that hindered clinic access. They described completing the online consultation promptly, discreetly and with ease. The information provided online was considered comprehensive, reassuring and helpful, but some overlooked it in their haste to obtain treatment. Participants generally described being able to collect treatment from pharmacies discreetly and promptly, but for some, poor awareness of the eSHC by pharmacy staff undermined their ability to do this. Those unsuitable for remote management, who were directed to clinic, described frustration and concern about health implications and clinic attendance. However, the helpline was a highly valued source of information, assistance and support. Conclusion The eSHC is a promising adjunct to traditional care. Its users have high expectations for convenience, speed and privacy, which may be compromised when transitioning from online to face-to-face elements of the eSHC. Managing expectations and improving implementation of the pharmacy process, could improve their experiences. Positive views on the helpline provide further support for embedding this ehealth intervention within a specialist clinical service.

Confidentiality of sexual health patients’ information – what has history taught us and where do we stand?

The rights of patients to access confidential care, without referral from, or sharing of, information with general practitioners or other health care professionals, is a founding principle of sexual health care in England. Indeed, the progressive Public Health (Venereal Diseases) Regulations 1916, described by Harrison in the first edition of the British Journal of Venereal Diseases, continues to influence the way that sexual health …

UG3 Are geosocial networking (GSN) apps associated with increased risk of STIs & HIV: A systematic review

Background/introduction Geosocial networking (GSN) apps such as Tinder and Grindr provide new ways of finding sex partners. It is suggested that usage could be responsible for increased STI & HIV transmission. Aim(s)/objectives To systematically review published literature to determine whether geosocial app use is associated with increased sexual risk behaviours, current and/or previous STIs & HIV. Methods Search of PubMed, EMBASE and Google Scholar for studies involving women, men, men who have sex with men (MSM) and use of GSN apps for sex-seeking which reported risk factors for STIs & HIV transmission, published from 2009 to March 2016, in English. Search terms were associated using at least one regarding GSN apps and a second regarding STIs or sexual risk behaviours. Quality was assessed using Critical Appraisal Skills Programme criteria. Results 13 studies met inclusion criteria: 12 cross-sectional studies, 1 review. All were in MSM from urban USA, China, Taiwan, UK and Ireland. In total there were 11924 subjects (range 92–7184). 7 studies reported app use to be associated with increased unprotected anal intercourse (UAI); 2 studies showed no association. 3 studies showed association with previous STI diagnoses, although association with HIV diagnoses had mixed results. 4 studies reported high response rate for app-based recruitment. Discussion/conclusion Use of GSN apps is associated with factors known to facilitate STI & HIV transmission in MSM. Studies in heterosexuals are much needed. High uptake of some app-recruited studies suggests GSN apps could be useful platforms for sexual health promotion and targeted risk reduction strategies.

Mixed-methods evaluation of a novel online STI results service

Objectives Evidence on optimal methods for providing STI test results is lacking. We evaluated an online results service, developed as part of an eSexual Health Clinic (eSHC). Methods We evaluated the online results service using a mixed-methods approach within large exploratory studies of the eSHC. Participants were chlamydia- positive and negative users of online postal self-sampling services in six National Chlamydia Screening Programme (NCSP) areas and chlamydia-positive patients from two genitourinary medicine (GUM) clinics between 21 July 2014 and 13 March 2015. Participants received a discreetly worded National Health Service ’NHS no-reply’ text message (SMS) informing them that their test results were ready and providing a weblink to a secure website. Participants logged in with their date of birth and mobile telephone or clinic number. Chlamydia-positive patients were offered online management. All interactions with the eSHC system were automatically logged and their timing recorded. Post-treatment, a service evaluation survey (n=152) and qualitative interviews (n=36) were conducted by telephone. Chlamydia-negative patients were offered a short online survey (n=274). Data were integrated. Results 92% (134/146) of NCSP chlamydia-positive patients, 82% (161/197) of GUM chlamydia-positive patients and 89% (1776/1997) of NCSP chlamydia-negative participants accessed test results within 7 days. 91% of chlamydia-positive patients were happy with the results service; 64% of those who had tested previously found the results service better or much better than previous experiences. 90% of chlamydia-negative survey participants agreed they would be happy to receive results this way in the future. Interviewees described accessing results with ease and appreciated the privacy and control the two-step process gave them. Conclusion A discreet SMS to alert users/patients that results are available, followed by provision of results via a secure website, was highly acceptable, irrespective of test result and testing history. The eSHC results service afforded users privacy and control over when they viewed results without compromising access.

Legislation and regulation in the era of online sexual health: how do we ensure provision of safe, high-quality care?

Advances in digital health and novel diagnostics for STIs and HIV have created new opportunities for people to access information, testing and, in some cases, treatment remote from traditional healthcare settings. Legislation and regulation can facilitate or impede innovation in service delivery. For example, the Health and Social Care Act of 2012 moved responsibility for public health, including the majority of sexual health services, from the National Health Service (NHS) to local government. Shifts in commissioning and service delivery have occurred, with major disinvestment in sexual health services, which has led to innovative models of care being introduced, including online services.1 There is an underlying but un-evidenced assumption that online sexual health services will preserve access and increase uptake at a reduced cost. This has led many services to introduce or expand their online presence, which ranges from simple unidirectional health promotion to more ambitious self-sampling services that aim to ‘channel shift’ those without symptoms away from face-to-face services and into online care. All healthcare professionals, healthcare services, and the medicines and devices they use are regulated, whether care is ‘traditional’ or remote, including online. Most regulations were established in the pre-digital era, although many professional bodies in the UK have adapted their existing guidance to incorporate online services. There are three key areas of regulation that are particularly relevant to online care: 1. Safety …