L Tickle

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.

Developing and testing accelerated partner therapy for partner notification for people with genital Chlamydia trachomatis diagnosed in primary care: a pilot randomised controlled trial

Background Accelerated partner therapy (APT) is a promising partner notification (PN) intervention in specialist sexual health clinic attenders. To address its applicability in primary care, we undertook a pilot randomised controlled trial (RCT) of two APT models in community settings. Methods Three-arm pilot RCT of two adjunct APT interventions: APTHotline (telephone assessment of partner(s) plus standard PN) and APTPharmacy (community pharmacist assessment of partner(s) plus routine PN), versus standard PN alone (patient referral). Index patients were women diagnosed with genital chlamydia in 12 general practices and three community contraception and sexual health (CASH) services in London and south coast of England, randomised between 1 September 2011 and 31 July 2013. Results 199 women described 339 male partners, of whom 313 were reported by the index as contactable. The proportions of contactable partners considered treated within 6 weeks of index diagnosis were APTHotline 39/111 (35%), APTPharmacy 46/100 (46%), standard patient referral 46/102 (45%). Among treated partners, 8/39 (21%) in APTHotline arm were treated via hotline and 14/46 (30%) in APTPharmacy arm were treated via pharmacy. Conclusions The two novel primary care APT models were acceptable, feasible, compliant with regulations and capable of achieving acceptable outcomes within a pilot RCT but intervention uptake was low. Although addition of these interventions to standard PN did not result in a difference between arms, overall PN uptake was higher than previously reported in similar settings, probably as a result of introducing a formal evaluation. Recruitment to an individually randomised trial proved challenging and full evaluation will likely require service-level randomisation. Trial registration number Registered UK Clinical Research Network Study Portfolio id number 10123.

‘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.

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.

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.

P197 An interpretative phenomenological analysis to explore the experiences of patients after speaking with a health adviser about partner notification

Introduction Partner notification (PN) is pivotal in controlling spread of sexually transmitted infections (STI) by reducing onward transmission and preventing reinfection. We explored the experiences of patients undergoing PN after being diagnosed with a STI. Methods 259 patients diagnosed with a STI over a 3 week period were invited to complete a PN survey comprising quantitative and qualitative questions. Qualitative data was analysed using Interpretative Phenomenological Analysis (IPA). Results 76 patients, 20 female and 24 male responded (not all questions were answered). Mean age was 31 (range 16-58). 21 identified as single and 16 partnered. 29% said this was their first clinic attendance, 65% said this was their first ever STI diagnosis and 36% said they attended as a STI contact. Eight main themes were identified: (1) infection source; (2) how to contact partners; (3) difficult information to discuss ‘specific sexual acts performed with every one of them’; (4) uncertainty of partner testing and treatment; (5) concern of providing partner details; (6) future expectations; (7) use of social media; and (8) Health Adviser (HA) qualities. Patients understand PN, but face barriers due to partnership dynamics and lack the skills required for PN. Further partners were contacted following consultation with a HA. Evidence of alternative PN being offered (i.e. provider referral) was limited. Discussion In line with BASHH guidelines, the importance of specialist staff in delivering PN was evident. Novel ways to facilitate sexual history taking and methods to contact partners (i.e. social media) are preferred and should be explored further.

O010 Use and perceptions of the Online Chlamydia Pathway (OCP): findings from qualitative interviews among people treated for chlamydia

Introduction Within the eSTI2 consortium, we conducted exploratory studies of an innovative Online Chlamydia Pathway (OCP: results service, automated clinical consultation, electronic prescription via community pharmacy, online partner management, with telephone helpline support). Access to traditional services was facilitated where appropriate. Objectives To describe patients’ use and perceptions of the OCP. Methods In-depth qualitative interviews with 40 purposively-sampled OCP users (21/40 female, aged 18–35) analysed thematically. Results Interviewees chose the OCP to obtain treatment rapidly, conveniently and inconspicuously, within busy lifestyles that impeded clinic access. They described completing the online consultation promptly and discreetly, often using smartphones. Many found the online information provided comprehensive, but those who completed the consultation in public locations and proceeded immediately to the pharmacy, described lacking information (which they apparently overlooked). Treatment collection from pharmacies was acceptable, but sometimes pharmacy staff lacked knowledge of the OCP (despite training), causing delays and conversations which threatened patients’ privacy – undermining the OCP’s perceived benefits. For those routed to clinic (as opposed to choosing to attend), the OCP’s anticipated benefits were also compromised. They described annoyance, anxiety, and did not always understand why a clinic visit was needed. The helpline was valued; users found it reassuring and informative. Conclusion The OCP is a promising adjunct to traditional care, particularly when integrated into sexual health services. Critical points in users’ journeys include the interface with pharmacies and clinics. Implementation issues in pharmacies need addressing. Management of users’ expectations and tailored information may improve the experience when routed to clinic.

OP34 Online care for sexually transmitted infections: using qualitative research in intervention development and evaluation

Background Sexually transmitted infections (STI) remain a major public health problem, despite widespread provision of STI testing and treatment through clinical services and chlamydia screening for young people in England. Early detection and treatment of these often asymptomatic infections is vital, but barriers to testing include embarrassment, privacy concerns, and inconvenience. Diagnostic technologies, which potentially enable STI self-testing within online care-pathways to treatment, are being developed; people could self-test and receive diagnoses and treatment ‘remote’ from health services, perhaps without interacting with health-professionals. Within a programme of research to develop this complex intervention, we qualitatively explored views and experiences, to inform its development and understand its acceptability. Methods In-depth interview study, with two phases (P1, P2). P1 explored, hypothetically, the acceptability of online care-pathways including STI self-testing, among 25 purposively-sampled college students, aged 16–24. P1’s findings informed development of the Online Chlamydia Pathway (OCP), which included an automated online consultation, treatment collection from community pharmacy, and a helpline for support and to facilitate clinic access where appropriate. P2: People diagnosed (following conventional testing) with chlamydia, were offered the OCP in an exploratory study. Interviews explored views and experiences of 40 purposively-sampled OCP users. Thematic analyses, using ‘Framework’ was used for data management. Results P1: 16 men and 9 women participated. Themes about speed, convenience and privacy (avoiding face-to-face consultations, concealing sexual healthcare use) were identified. Self-testing within online care-pathways was discussed as more convenient, private and quicker than existing services. Interviewees expressed concern about electronic ‘evidence’ of sexual healthcare use, and self-operation of novel technology. They valued the option of support from health-professionals. Association with NHS services conveyed trustworthiness. In response to these findings, the OCP was delivered as a web-app, text-messages were worded discreetly, NHS logos displayed, and a helpline and facilitated clinic access were included. P2: 19 men and 21 women, aged 18–35, participated. Themes about speed, convenience and privacy were further developed, but some described how these perceived advantages were compromised when they collected treatment in pharmacies. Interviewees expressed few, minor concerns about internet/‘technological’ privacy risks, and appreciated the OCP’s association with existing NHS services. They favoured the helpline’s presence, those using it gaining reassurance. Conclusion This novel intervention’s ongoing development has been iteratively informed by qualitative research. Although it was perceived as an acceptable alternative to conventional sexual healthcare, linkage with existing services and optional human support remained important. Further research is needed regarding other risk groups and infections, and the future self-test.