Terry Hogan

Internet-based Screening for Sexually Transmitted Infections To Reach Nonclinic Populations in the Community: Risk Factors for Infection in Men

Background: Internet-based screening for sexually transmitted infections (STIs) has been acceptable to women, and can reach high-risk populations. No prior published data describe internet-based screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis in men. We studied whether internet-based screening was acceptable and reached a high-risk population, and what risk factors were associated with STI positivity. Methods: The website, www.iwantthekit.org, encouraged men ≥14 years of age to request a home self-sampling kit and a questionnaire on risk factors and acceptability of internet-based screening. Penile swabs and urine samples were tested for C. trachomatis, N. gonorrhoeae, and T. vaginalis using a nucleic acid amplification test. Risk factors and acceptability were examined using chi squared tests and logistic regression. Results: Of 501 samples received for testing, 106 (21%) were positive for at least one STI, 64 (13%) for chlamydia, 4 (1%) for gonorrhea, and 49 (10%) for trichomonas. In multivariable analyses, age, race, household income, and frequency of condom use were independently associated with infection with at least one STI. Of the total respondents, 34% had a prior STI; 29% reported having a partner with an STI, but only 13% reported always using a condom. Among the men who participated in this study, 77% preferred a self-administered specimen versus attending a clinic, 89% reported that swab use was easy, and 89% reported that they would use internet-based screening again. Conclusions: Men who accessed internet-based screening had known risk factors for STIs and had a high prevalence of infection. Internet-based screening was acceptable and could reach these high-risk men who might not otherwise be reached through traditional means.

Can E-Technology Through the Internet be Used as a New Tool to Address the Chlamydia trachomatis Epidemic by Home Sampling and Vaginal Swabs?

The Internet provides patients, as well as clinicians with immediate, confidential access to information about sexually transmitted diseases (STDs).1,2 Young individuals are avid users of the Internet and usage has been considered to be a risk factor for STDs.3–7 Data indicate that there are 246,402,574 North American Internet users.8

High rates of depressive symptoms in STD clinic patients.

Background Depressed mood syndromes may limit the ability of patients with sexually transmitted diseases (STDs) to process risk reduction messages and change behavior. We undertook screening for depression in an urban STD clinic. Goal To define the prevalence of depressed mood among STD patients in Baltimore, Maryland. Study Design A convenience sample of 125 patients presenting to an STD clinic completed the 30-item General Health Questionnaire (GHQ). Endorsement of ≥ 6 depressive symptom items on the GHQ was considered probable depression. Results Of 125 patients screened, 39.2% had GHQ scores above the threshold. Women were more likely to have probable depression than men (51.9% versus 31.9%, P = 0.023). There was no association of substance use and depressed mood, nor of a diagnosed STD and depressed mood. Conclusions Depressive symptom rates are extremely high among STD patients, which may compromise the success of risk reduction counseling.

Trichomonas vaginalis infection in women who submit self-obtained vaginal samples after Internet recruitment

Background: Submission of self-obtained vaginal samples (SOVs) collected at home could remove barriers that women face in getting tested for sexually transmitted infections (STIs). Internet recruitment of SOVs is highly acceptable. Methods: Sexually active women ≥14 years were recruited by an educational Internet program, available at: www.iwantthekit.org (IWTK), which offered free testing for trichomonas as part of a panel, which also offered testing for chlamydia and gonorrhea. Kits were ordered online, SOVs were sent through US mail to the laboratory, and tested by nucleic acid amplification tests. Demographics and sexual risk factors were accessed by questionnaires. Women called or were contacted to receive their results. Results: Of women requesting kits, 1525 (43%) returned swabs by mail. In all, 61% were <25 years, 52% were black, and 80% were single. Vaginal discharge was reported by 44%, prevalence for trichomonas was 10% (10% for chlamydia, 1% for gonorrhea), and 18% had at least one prevalent STI. Multivariate logistic regression demonstrated several significantly associated risks factors as follows: adjusted odds ratio for black race was 2.69; for residence of Illinois, 3.85; for not having health insurance, 1.57; for lack of a bachelors degree, 5.53; for having 2 to 15 partners, 1.60; for having ≥16 partners in previous year, 3.51; for being bisexual, 2.0; for not always using condoms, 3.04; and for having a partner who had a previous STI, 1.71. Age was not associated with trichomonas infection. All infected women were treated. Conclusions: A high prevalence of trichomonas and high sexual risk factors were demonstrated. Internet recruitment was a useful method of screening women for trichomonas infection.

Characteristics and predictors of women who obtain rescreening for sexually transmitted infections using the www.iwantthekit.org screening programme.

Professional organizations recommend rescreening chlamydia-infected women. The iwantthekit Internet-screening programme offered rescreening opportunities by using iwantthekit. Mailed, home-collected vaginal swabs were tested for chlamydia, gonorrhoea, and trichomoniasis by nucleic acid amplification tests. Demographics and risk behaviours of repeat users were determined from questionnaires. Predictors of repeat users were measured in a matched case–control study. Of 1747 women, 304 (17%), who used iwantthekit, indicated they had used the kit previously. Mean age was 24.7 ± 5.7 years and 69% were African-American. Repeat iwantthekit users were more likely to be aged ≥20 years (OR = 2.10); were more likely to have been treated for a sexually transmitted infection (OR = 2.32); less likely to drink alcohol before sex (OR = 0.63); and to never use condoms (OR = 0.43). Of repeat users, 84.2% had a negative prior test and 15.8% had a positive. At current test, 13.2% were infected. Previous trichomoniasis was associated with current trichomoniasis (p < 0.05). The iwantthekit may offer rescreening opportunities for previously infected women.

Chlamydia trachomatis Age-Specific Prevalence in Women Who Used an Internet-Based Self-screening Program Compared to Women Who Were Screened in Family Planning Clinics

Objectives: To determine whether women who collect self-collected vaginal swabs at home demonstrated a higher positivity of Chlamydia trachomatis than women in family planning clinics. Methods: Collection kits for vaginal swabs were internet requested, collected at home, and mailed to a laboratory for testing; questionnaires were completed about acceptability and sexual risk history. Infected women received treatment at participating clinics. Age-specific prevalences were compared to those from family planning clinics. Results: Chlamydia positivity was 10.3% for 1171 females mailing swabs; prevalences ranged from 3.3% to 5.5% in family planning. Positivity for internet age groups was much higher than those for family planning age groups. The positivity for internet participants ranged from a low of 4.4% in Baltimore in 2005 to a high of 15.2% Baltimore in 2007. Family planning clinic prevalence in Baltimore and Maryland ranged from a low of 3.3% in Baltimore in 2006 to a high of 5.5% in Baltimore in 2008. The median age for all years for internet users in Baltimore and Maryland combined was 23 years; the median age for all years for attendees to family planning clinics who had chlamydia testing performed was 23 years. Conclusions: Internet recruited women demonstrated higher positivity of chlamydia than those in family planning, providing new options for chlamydia screening programs.

Point-of-care tests for sexually transmissible infections: what do ‘end users’ want?

BACKGROUND Clinicians and developers identify sensitivity as an important quality in a point-of-care test (POCT) for sexually transmissible infections (STIs). Little information exists regarding what patients want for STI POCTs. METHODS A qualitative study, encompassing five focus groups among attendees of STI and adolescent health centres in Baltimore, Maryland, and Cincinnati, Ohio, were conducted between March 2008 and April 2009. Discussion topics included advantages and disadvantages of having a POCT, perceived barriers to using POCTs in the clinic setting and at home, priorities for the development of new POCTs for STIs, and envisioned characteristics of an ideal POCT. All discussions were recorded and transcribed. A qualitative content analysis was performed to examine frequencies or patterns of recurring codes, which were regrouped and indexed to identify salient themes. RESULTS Patients attending STI and adolescent outpatient clinics are in favour of diagnostic tests that are rapid, easy to read and simple to use. Home testing options for POCTs were acceptable and provided better confidentiality, privacy and convenience, but clinic-based POCTs were also acceptable because they offer definitive results and ensure immediate treatment. Barriers to home POCTs centred on cost and the ability to read and perform the test correctly at home. Opinions did not differ by patient ethnicity, except that Hispanic participants questioned the reliability of home test results, wanted high sensitivity and desired bilingual instructions. CONCLUSIONS Patients attending STI and adolescent medical centres are in favour of STI POCTs if they are affordable, rapid, easy to read and simple to use.

P48 Yearly trends for the internet recruitment program, http://www.iwantthekit.org—what happened to the STI prevalence?

Background The iwantthekit (IWTK) internet recruitment screening program began in 2004 and offered an opportunity to determine trends in prevalence for women and men were screened for STIs. Objectives To determine significance in trends for STIs for the population accessing screening over time. Methods Participants were recruited via the internet to request home collection kits and to collect either vaginal or penile swabs at home with subsequent mailing to a laboratory for screening for chlamydia (CT), gonorrhoea (GC), and trichomonas (TV) by NAATs. Prevalence for women and men were calculated by year and race for 2004–2011 for each organism. Linear regression analysis was performed to determine significance of temporal trends in gender-, STI-specific prevalence controlling for annual demographic composition of participants. Results 3363 women were screened for CT and GC from 2004 to 2011; TV screening was added in 2006 (N=2692). From 2006 to 2011, 1370 men were screened for CT, GC, and TV. Prevalence varied: CT: 5.5%–10.6%; GC: 0.3%–2.7%; TV: 5.8%–13.3% for females and CT: 8.0%–15.4%; GC: 0.7%–1.9%; TV: 0.8%–12.4% for males. Most users were from Maryland (70.1%). The only statistically significant linear downtrend by year was CT prevalence in male participants <25 yr from 23.1% in 2007 to 12.5% in 2011, which was 2.4%/yr (p=0.012); while the prevalence in male ¡Ý25 years remained relatively stable from 6.2% in 2007 to 5.5% in 2011 (p=0.911). The remainder of STI prevalences in females and males did not show a downward linear trend by calendar year. GC prevalence in females was significantly correlated with the per cent of Black participants (p=0.030), while TV prevalence in females was positively associated with the number of participants <25 yr (p=0.032). Conclusions IWTK attracted participants with high-risk sexual behaviours to use home collection for STI testing. Prevalence by year and by organism, for the most part, did not show a significant downward trend.

O1-S07.02 Characteristics of women testing positive for rectal STIs using self-collected mailed specimens

Background The website http://www.iwantthekit.org/ (IWTK) began offering self-administered rectal swab kits in addition to vaginal swab kits in January 2009 to test for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Methods Swab samples were collected at home by participants and sent by US mail and tested by NAAT (Gen-Probe) assays. Participants submitted separate questionnaires for the vaginal and rectal kits. Data were analysed by STATA, version 11. Results In 1084 questionnaires from women submitting vaginal swabs to the IWTK program since 2009, 194 (17.9%) reported anal intercourse (AI) in the last 90 days. Of these women, only 113 (58.2%) also ordered and returned rectal kits for testing. An additional 95 kits were ordered and returned by women who did not report recent AI (82), did not return a vaginal swab (5), or did not answer the AI question on the vaginal questionnaire (8). From a total of 406 rectal kits ordered by women overall, 208 (51.2%) were returned; three had no consent form; thus, 205 were tested. Of those tested, 26 (12.7%) were positive for chlamydia, 5 (2.4%) were positive for gonorrhoea, and 13 (6.3%) were positive for trichomoniasis. Two of these samples were positive for both Chlamydia and gonorrhoea, two for both chlamydia and trichomonas, and one for all three STIs. The total number of women testing positive for any rectal STI was 38 (18.5%), and 35 of these women also received and returned vaginal swabs, 34 of which were tested. Of those tested, 24 (70.5%) were positive for at least one of the three STIs vaginally, indicating that women who tested positive for rectal STIs were at very high risk for vaginal STIs. Of the 38 women with rectal STIs, the median age was 22 yr. and the median age of first rectal sex was 20 yr. Questionnaires demonstrated 93.6% were single, 62.5% were Black, and 21.9% were White. Of the women with rectal STIs, 67.7% reported no symptoms, 12.0% reported no rectal partners in previous yr, 56.0% reported one partner, and 32% reported 2–4 partners. Only 16.0% reported having a new rectal partner in the last 3 months. Half (50.0%) reported never using condoms, 15.4% reported they always used condoms, 15.4% reported using condoms most of the time, and 19.2% reported using condoms some of the time. Conclusions Public health officials should be aware that AI and rectal STIs are not uncommon among sexually active women. Future STI screening programs should consider rectal infections.

P1-S6.18 Characteristics of men who seek rescreening for STIs after once using the http://www.iwantthekit.org screening program

Background The iwantthekit (IWTK) Internet screening program offered an opportunity to study characteristics of men who seek rescreening, as well as determine reported infected status at the previous screening. Methods We determined characteristics of male repeat users from questionnaires. Predictors of repeat users were identified in a matched case-control study by conditional logistic regression analysis. A case was defined as reporting ever having used IWTK before. A control was a user who reported never using the program before. Two controls were systematically sampled for each case by matching the date of use IWTK of the case within 3 months. Results During 2007–2010, 115 (14%) of 852 men who used IWTK for STI testing, indicated that they had used IWTK previously. Among them, 43% used it >2 times. Mean age was 25.8 yr ±8.5 yr, and 90% were currently sexually active. 17% reported having sex with a male; 35% had >5 partners in the past yr; 58% had new partners in last 3 months; 49% currently were having sex >1 person. 63% had been treated for an STI: chlamydia (CT)(74%), trichomonas (TV)(42%) and gonorrhoea (GC)(23%); 6 reported being treated for HIV. By matching time of enrolment, 230 controls were selected. In the multivariate analysis, repeat IWTK users were more likely to be <30 years (OR=2.04, 95% CI 1.04 to 4.02), have health insurance (OR=2.01, 95% CI 1.10 to 3.69), reported ever being tested for an STI (OR=2.01, 95% CI 1.02 to 3.97), ever been treated for an STI (OR=2.20, 95% CI 1.14 to 4.23), particularly TV (OR=5.16, 95% CI 1.80 to 14.81), and less likely to have penile discharge currently (OR=0.24, 95% CI 0.08 to 0.76). Of male repeaters, 80.9% reported previous test results from IWTK as negative and 22/115 (19.1%) reported previous result positive–11 had CT, 4 had GC, 8 had TV; 2 of these were mixed infections. At present test, 24 tested positive–19 had CT, 3 had GC, 5 had TV; 3 were mixed infections. Reported CT positivity in last test was associated with current CT test positivity (p<0.05). Conclusions The Internet screening program IWTK attracted a number of previous male users of IWTK, who practiced high-risk sexual behaviours, to use the program for repeat STI testing. IWTK provided an alternate approach for rescreening previously infected men as well as men reporting high-risk behaviours.