Abstract
Men who have sex with men (MSM) have higher rates of poor sexual health. The National Institute for Health and Care Excellence has produced guidance on increasing the uptake of HIV testing to reduce undiagnosed infection in MSM. We report the results of a pilot outreach sexually transmitted infection service using nurse-delivered screening and self-sampled postal testing at a sex on premises venue with comparison made against a sexual health clinic service. Thirty men were included in each group. Users of the nurse-delivered and postal services were older (nurse service median age 57.5 years vs. postal kit service 47 years vs. clinic 35.5 years, p ≤ 0.001). Outreach groups were less likely to have undertaken sexually transmitted infection testing previously than the clinic group (53.3% and 60% vs. 93.3%, p ≤ 0.001). Chlamydia trachomatis and Neisseria gonorrhoeae testing uptake was comparable across groups (nurse outreach 86.6%, ‘do it yourself’ postal kit 100% vs. clinic 100%, p = 0.032), but uptake for blood tests was lower in the postal kit group (nurse outreach 83.3%, postal kit 53.3% vs. clinic 100%, p ≤ 0.001). No significant difference in active sexually transmitted infection positivity across the groups was observed. This combination outreach screening approach is effective in targeting MSM who use sex on premises venues.
Keywords
Introduction
Men who have sex with men (MSM) have significantly higher rates of sexual health morbidity than the general population. MSM are at particularly high risk of acquiring HIV and syphilis infections, which if left undiagnosed can lead to significant ill health and onward transmission of infection. 1
In recent years, public health policy has focused on increasing access to HIV testing for those at high risk of infection. The National Institute for Health and Care Excellence has published guidance on increasing HIV and viral hepatitis testing in MSM.2,3 Community venue testing is regarded as an important element in increasing access to testing, and the guidance specifically recommends outreach testing in sex on premises venues. The former Health Protection Agency (HPA) now Health Protection England (HPE) in 2010 published a report reviewing strategies for expanding HIV testing. Based on evidence from community testing pilot schemes, they concluded that community HIV testing had the potential to increase access to testing and were successful in identifying individuals with previously undiagnosed HIV infection. 4
In response to these recommendations, we implemented a novel screening service incorporating nurse-delivered screening and self-sampled postal testing kits, for asymptomatic MSM at a local sauna. This venue is located in a predominantly rural area where a recent service needs assessment identified MSM as a particularly hard to reach group using current standard NHS sexual health services. 5
HIV testing in sex on premises venues used by MSM, particularly saunas, has been shown to be an effective and acceptable method of community testing. 6 Blood sampling using dried blood spot (DBS) technology has been validated for blood-borne viruses and syphilis testing and provides a suitable method for remote testing and self-sampling.7,8 Self obtained samples for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) using Nucleic Acid Amplification Tests (NAATS), particularly the Gen-Probe AptimaCombo2™ platform, has been showed to be acceptable to service users and equivalent in accuracy to practitioner taken samples.9,10 CT and NG testing on an outreach basis has also been shown to detect high levels of infection. 11 To our knowledge, no current UK National Health Service (NHS)-funded service combines both DBS and triple anatomical site CT/NG testing for remote self-sampled screening. The packaging together of self-sampled postal screening and nurse-delivered screening/vaccination is a novel way of maximising sexually transmitted infection (STI) screening in this hard to reach group. In this paper, we present the results of a pilot outreach STI service using nurse-delivered screening and self-sampled postal testing kits at a sex on premises venue with comparison made against screening within a sexual health clinic.
Methods
To achieve maximum access to STI testing for MSM using a local sauna, in 2013, a pilot nurse-delivered outreach screening service was established alongside constantly available ‘do it yourself’ (DIY) postal self-sampling screening packs.
The DIY postal kits consisted of self-taken pharynx, urine and rectal CT/NG samples (Gen-Probe, AptimaCombo 2™) and self-sampled finger-prick DBS collection system for HIV, syphilis, hepatitis B and hepatitis C screening. Users completed a personal details and contact preference form and returned this with their samples, via a Royal Mail freepost™ service, to our sexual health clinic for processing.
The nurse-delivered outreach service consisted of a monthly asymptomatic screening clinic held within the venue undertaken by a trained sexual health nurse practitioner and health care assistant. Health promotion advice was offered, and CT and NG samples were taken using the Aptima Combo 2™ system. Service users had the option of self-taken or practitioner-taken samples. Blood-borne virus and syphilis screening were offered via venous blood samples or DBS collection. Hepatitis B vaccination was also offered and administered on site. Both nurse and DIY postal kit services were initiated simultaneously.
We worked in partnership with a local health promotion charity that provided on-site health promotion advice and support to sauna users and facilitated the use of DIY postal kits. Health promotion workers were present at the venue three days per week, including the days when sexual health outreach nurses visited. All health promotion workers had undertaken locally delivered training in motivational interviewing, sexual health promotion and STI testing.
A retrospective review of records for the first 30 nurse-delivered service and DIY postal kit clients was undertaken. The service pilot was undertaken between April 2013 and December 2013. The records of the first 30 asymptomatic MSM attending the local sexual health clinic in 2013 were also reviewed to allow a comparison with the current standard of care and as a guide to local STI positivity rates in asymptomatic MSM. All MSM using clinic and outreach services had the same screening tests performed.
Although DIY postal kit and nurse-delivered services are considered to be part of one novel outreach service, we have presented the data for the two groups separately to allow comparison between the two outreach strands.
Data were analysed using SPSS version 21, and descriptive statistics and one-way analysis of variance (ANOVA) methods were used to allow comparisons to be drawn between groups. Failed tests were excluded from the analysis; however, when CT/NG were tested at multiple anatomical sites and tests from one site failed but others were successful, and the client was maintained in the CT/NG at any site analysis.
Results
Summary results for outreach and standard of care screening services for the first 30 users of each service.
One-way ANOVA. All other p values obtained via Fisher’s exact test.
Failed tests excluded from analysis.
Active Hepatitis B or C infection defined by standard Serological/Polymerase Chain Reaction (PCR) testing evidence of active infection.
Cleared infection defined by Hepatitis B core and surface antibody positivity, but surface antigen negative. Hepatitis C cleared infection defined by negative PCR test.
No user was identified to have more than one infection.
Discussion
Men using the outreach services were older and less likely to have undertaken previous STI testing. Fewer men using the DIY postal kit service performed blood tests, and this may represent a reluctance to use self-sampling methods. There were no significant differences in STI positivity rate across the groups; however, more cleared viral hepatitis infections were found in the DIY postal kit test group. Test rejection and failure rates were comparable across the groups. Rates of successful results communication were lower in the DIY postal kit and outreach nurse groups than the hub clinic groups (13.4% and 3.4% lower, respectively); however, this did not reach statistical significance.
Remote self-sampling itself has its merits and disadvantages. It can increase access to testing and provide a convenient, private method of STI testing; however, it is not suitable for symptomatic clients. Careful attention needs to be paid to the supporting information provided with self-sampling kits as the method lacks the opportunity for professional risk assessment and advice. During this pilot service, we ensured that there was an opportunity to access health promotion advice from an appropriately trained individual and regarded the kits as a back up resource to the nurse-delivered service.
The results of this pilot service have shown that a locally provided, nurse-delivered outreach service in combination with DIY postal self-sampling tests can provide an effective means of STI testing in a group that may not access traditional sexual health services but visit sex on premises venues. By using remote testing strategies in partnership with third-sector health promotion organisations access to testing can be maximised, this may allow some to test for the first time.
This service has been supported by local sexual health commissioners and an increase in nurse-delivered clinics at the sauna has been funded. There are now plans to expand this service to other hard to reach groups including female and male sex workers at local commercial sex venues. It is hoped in the current economically challenged environment that these results will aid decisions made by local public health commissioners on whether funding for this type of service is justified in the longer term.
Footnotes
Ethical review
National Research Ethics Service advice was sought (Ref 55/57) the project is considered to be research but does not require review by an NHS Research Ethics Committee.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.