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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Curr Opin Infect Dis. Author manuscript; available in PMC Feb 1, 2012.
Published in final edited form as:
PMCID: PMC3125396
NIHMSID: NIHMS301955

Screening for STIs at Home or in the Clinic?

Abstract

Purpose of review

To assess the evidence to support home versus clinic-based screening for sexually transmitted infections.

Recent findings

Home-based screening for sexually transmitted infections has been shown to be a feasible approach for men and women from a variety of settings, including high risk, low income, and resource-poor communities. In recent studies, the testing rate with home-based screening was up to 11 times greater than the testing rate with clinic-based screening. For most individuals, self-collection and testing of urine or vaginal specimens at home was considered to be easy, acceptable, and often preferred over testing at a clinic. There is limited evidence with regard to the cost-effectiveness of home-versus clinic-based screening for sexually transmitted infections. However, a study from the U.S. concluded that home-based screening is cost saving.

Summary

Improvements in screening rates for sexually transmitted infections can be achieved with home-based screening methods. Making low-cost home test kits available may encourage at-risk young individuals with less access to clinic care, who may not otherwise be screened, to self-test for sexually transmitted infections.

Keywords: Sexually transmitted infections, screening, home testing, home-obtained specimen, postal specimen

Introduction

In the United States, chlamydial and gonorrheal infections are a major public health concern as they remain the most common reportable infectious diseases in the country. More than 1.5 million cases of chlamydia and gonorrhea were reported to the Centers for Disease Control and Prevention in 2008[1]. Screening for sexually transmitted infections (STIs) is particularly important since most infections with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are asymptomatic and remain undiagnosed or untreated [2, 3]. Major sequelae can result, including pelvic inflammatory disease (PID), tubal infertility, ectopic pregnancy, and chronic pelvic pain in women, and epididymitis in men [46].

Home-based screening strategies using self-collected, mail-in specimens are a feasible approach to screen for STIs, and have been implemented in many population-level screening studies in Sweden [7], Denmark [8], the United Kingdom[9, 10], and the Netherlands [11, 12]. Additional evidence suggests that home-based STI tests may be even more acceptable and effective than traditional STI testing at a clinic[8, 13]. This review examines the published literature from January 2007 to August 2010 for studies comparing home-with clinic-based screening for STIs.

Randomized controlled trials

We identified a total of 7 randomized controlled trials (RCTs) comparing home-versus clinic-based STI screening(Table 1). The literature review included a PubMed/MEDLINE search of the literature from January 2007 to August2010 (MeSH terms: sexually transmitted diseases; Chlamydia trachomatis; chlamydia infections; Neisseria gonorrhoeae; mass screening; home care services; self care; self-examination; postal service; specimen handling; and reagent kits, diagnostic) and review of bibliographies of key articles in the medical literature. Of the 7 RCTs, 3 were conducted in the U.S. [14**, 17*, 18]and 2 were conducted in lower-income populations in South Africa and Brazil [19*, 24*]; the remaining 2 studies focused primarily on home-based methods for contact tracing as opposed to STI screening[15, 16], and therefore are not discussed in this review. Of note, we found7 additional RCTs outside of the review period, including 2 large trials conducted in Denmark[8, 13], a study in Scotland [25], a study examining STI rescreening [26], as well as 2 RCTs centered on partner management and contact tracing[27, 28], and an RCT follow-up study which examined the incidence of PID one year following either home-or clinic-based STI screening[29].

Table 1
Studies comparing home-with clinic-based screening for STIs

Studies conducted in the United States

The most recent RCT comparing home-with clinic-based STI screening was conducted by Graseck and colleagues in St. Louis, Missouri[14**]. The results of this trial were an extension of their findings in an earlier observational study, described in further detail later in this review [20**]. In this RCT, 558 women using long-acting reversible contraception (LARC) were randomized to STI screening at home or at a clinic, either with their regular healthcare provider or at1 of4 family planning clinics. A total of 243 women (44.3%) completed STI screening. However, women were more likely to complete screening when they were randomized to receive a home test kit(56.3%) than when they were invited to screen at a clinic (32.9%, RR 1.7, 95% CI 1.4–2.0). Furthermore, of 122 women who completed a survey regarding testing satisfaction, all women reported use of the vaginal self-swab to be easy, and 70% felt self-collection of vaginal samples was extremely easy. The majority of home-testers (83%) also preferred home STI testing in the future, whereas only 49% of clinic-testers preferred to be tested at a clinic (p<0.001). These results suggest that, compared to traditional screening at a clinic, home-based STI screening is a more effective and favored screening approach among women. Home screening may encourage more women to complete testing, particularly for LARC method users who may be less likely to visit a clinic compared to those using other contraceptive methods.

In Seattle, Washington, a population-based, randomized STI screening trial was conducted to compare the effectiveness of 3 different outreach methods to improve the rates of chlamydia screening in men [17*]. Between November 2001 and October 2002, 8,820 men ages 21–25 years from a managed care plan were randomized to 1 of 3 different screening strategies: 1) an invitation letter offering CT screening in addition to a card that could be mailed back to request a home test kit; 2) an invitation letter in addition to direct mailing of a home test kit; or 3) usual clinical care(control group)where STI testing was provided only if the participant presented to one of the managed care clinics. A reminder letter was sent to the men in the 2 intervention arms after 3–4 weeks had elapsed. At 4 months post-randomization, significantly more men completed CT testing when they were sent an invitation letter in addition to either a test-request card (3.6%, relative risk [RR]5.6, 95% CI 3.6–7.8) or direct mailing of a home test kit (7.8%, RR 11.1, 95% CI 7.3–16.9)compared to usual clinical care (0.8%). However, more men completed CT testing when they received a home test kit directly than when they were asked to mail back a test-request card (RR 2.3, 95% CI 1.8–2.9). While these results suggest that home-based STI screening is more effective than clinic-based screening, they are limited by the fact that the intervention groups received screening invitations and reminder letters, whereas the control group received neither. In effect, the intervention group received co-interventions that may have encouraged men to complete STI testing beyond that of a home test kit or test-request card alone.

In the Detection Acceptability Intervention for STDs in Young Women (DAISY) study, home-based STI screening similarly out-performed clinic-based screening [18]. Four hundred and three women, ages 15–24 years, with recent STIs or risk factors for STIs were recruited from clinics and surrounding neighborhoods, and randomized to receive repeated STI screening at 6, 12, and 18 months post-enrollment either at a clinic or at home. Postcards were sent to the clinic group at 6, 12, and 18 months inviting the women to attend STI screening at the clinic, whereas home test kits were picked up by or directly mailed to the home testing group at 6, 12, and 18 months. By the end of the study, women in the home testing group completed more overall tests than those in the clinic group (RR 1.38, 95% CI 1.23–1.55), and they completed more tests when they were asymptomatic (RR 1.57, 95% CI 1.34–1.83). The investigators concluded that home STI screening is a feasible approach to improve STI screening rates in high-risk young women, particularly those with less regular attendance at healthcare clinics.

Studies conducted in low income and resource-poor communities

Two similar trials were conducted concurrently in South Africa and Brazil comparing home-with clinic-based screening for GC, CT, and Trichomonas vaginalis (TV)[19*, 24*]. In Gugulethu, South Africa, Jones and colleagues randomized 626 women to self-collection using a test kit at a clinic under supervision of a nurse, or using an identical test kit at home to be mailed back to study staff[19*]. Women in the home testing group(60%)were more likely to self-collect a vaginal sample than women in the clinic testing group (42%, RR 1.4, 95% CI 1.2–1.7), and a majority of women in both the home and clinic testing groups said self-collection was easy/very easy. However, compared to home-testers, more clinic-testers reported self-collection to be easy/very easy (96.2% versus 85.5%, RR 1.12, 95% CI 1.03–1.22). Among home-testers, self-collection at home was acceptable and preferred by a majority of women (58%), whereas most clinic-testers (66%) preferred self-collection at the clinic. These findings indicate that self-collection of vaginal specimens for STI screening is a feasible practice in both clinic and home settings. Making home test kits easily available may be particularly valuable in this setting as 22% of women in the study population tested positive for CT, 10% for TV, and 8% for GC.

A randomized trial with similar methodology was conducted by Lippman and colleagues in São Paulo, Brazil in which 818 low-income women were randomized to self-collect vaginal specimens with STI test kits either at a clinic or at home[24*]. However, in this study, participants were required to drop off their completed test kits at the clinic instead of mailing it to study staff, eliminating much of the benefit of home STI testing. The testing rate was nevertheless slightly higher among home-testers (93%) compared to clinic-testers (89%) at their 6-week follow-up visit (RR 1.04, 95% CI 1.00–1.09). Similar to the findings of Jones and colleagues, a majority of home-testers(61%)preferred self-collection at home; however, only 26% of clinic-testers preferred home-based testing in the future. The randomization group most strongly predicted a woman’s testing preference. In this setting as well, offering home test kits appears to be feasible as 96% of all participants said self-collection of vaginal samples was easy, and that they felt comfortable doing so.

Observational studies

Our PubMed/MEDLINE search returned 2 relevant controlled, observational studies within the study period that compared home-with clinic-based STI screening(Table 1) [20**, 21]. As mentioned previously, Graseck and colleagues conducted an observational study as a prelude to their RCT. Their observational study examined the selection and STI testing rates of 462 women who were offered the option of STI testing at home or at a clinic[20**]. A majority of women (75.5%) chose home-based STI testing, whereas only 16.1% and 8.2%chose to be tested at a family planning clinic or with their own providers, respectively; all comparisons were significantly different from one another (p<0.001). Overall, 56.6% of women completed STI testing, but home-testers were more likely to complete testing than clinic-testers (64.6% versus 31.6%, RR 2.04, 95% CI 1.51–2.76). The investigators’ findings indicate high acceptability of home-based STI screening among women and suggest that home-based approaches may be more effective in improving STI screening rates than testing in traditional clinic venues.

Another study in Scotland compared different outreach strategies for chlamydia screening in venues outside of genitourinary medicine clinics [21]. Williamson and colleagues offered home test kits at commercial settings (e.g., record stores, pharmacies), asexual health clinic, and local colleges, as well as clinic-based testing conducted by nurses at the sexual health clinic or on college campuses. A total of 4,475 young men (15.2%) and women (84.8%), ages 13–25 years, completed testing, of which 51.3% completed home test kits, 42.0% tested at the clinic, and 6.7% tested on college campuses. A majority of men (80.2%) used home test kits, whereas only 46.1% of women were home-testers and 48.1%were clinic-testers. The CT incidence was 12.3% among men and 10.6% among women. These findings indicate that distributing home test kits at commercial venues is a feasible approach and suggest that home testing may be a particularly good option to increase STI screening rates in men.

Economic and cost analyses

We identified 2 studies from our PubMed/MEDLINE search which discussed the costs and cost-effectiveness of home-based STI screening(Table 1) [22, 23]. In the UK, Roberts and colleagues used a transmission dynamic model to compare the cost-effectiveness of population-based STI screening using home test kits compared to a policy of no organized screening (i.e., mostly opportunistic screening where individuals are screened for STIs during clinic visits for other reasons)[22]. The investigators concluded that home-based screening was not cost-effective. However, we noted several limitations to this report. The study’s primary objective was to evaluate a systematic, population-level STI screening program in the UK compared to opportunistic screening; it is not a direct assessment of home versus clinic-based STI screening. In addition, the investigators did not include chronic pelvic pain as a fairly common and costly adverse outcome of PID. Thus, this study will not be discussed in further detail in this review.

In the U.S., Smith and colleagues compared the costs associated with STI screening at home versus at a clinic [23] using data gathered from the DAISY study described previously [18]. Clinic testing was calculated to cost $111 per test, including $49 in direct costs and $62 in indirect costs such as transportation, child care, and missed work(2005 prices). In comparison, home testing was calculated to cost $25 per test, which was determined to be cost saving for the overall study population. When only participants recruited from clinics were considered, a group with higher baseline clinic utilization rates, home testing was also found to be cost saving because the availability of home test kits allowed this subset of women to reduce their use of clinic services. However, when considering only the subset of women recruited from surrounding neighborhoods, home testing was not considered cost saving because the increase in home testing was not accompanied by a corresponding reduction in clinic testing. This result does, however, suggest that home screening may tap at-risk populations that might normally have less access or inclination to utilize clinic services for STI screening, which may prove to be cost saving from a public health perspective.

Strengths and Limitations

Recent studies comparing home-with clinic-based STI screening include both men and women from a wide range of social and economic settings, and several are conducted as RCTs, providing stronger evidence that home test kits can be used effectively to test for STIs. However, these studies are also limited because they differ widely in methodology. While participants in some studies may have been more encouraged to complete home testing because of study elements like reminder letters, participants in other studies may have been less encouraged to complete home testing because, for instance, they were required to hand-deliver their test kits to the study clinic. Cost-effectiveness studies are also limited because they do not account for all of the direct and indirect costs associated with STI complications and treatment, and they are based on different estimates of screening uptake and STI complication rates.

Conclusion

The recent evidence indicates that home-based STI screening is a feasible, well-accepted, and often the preferred approach to test for STIs compared to testing at a traditional clinic venue. In almost all studies, higher testing rates were achieved with home-compared to clinic-based STI screening in both men and women. This suggests that improved STI screening rates might be achieved among young individuals, particularly those with less clinic access, by increasing the availability of home STI test kits. Further investigation needs to be made with regard to the cost-effectiveness of home versus clinic-based STI testing based on population-specific estimates of screening rates, STI prevalence, and incidence of adverse STI outcomes such as PID, ectopic pregnancy, chronic pelvic pain, and infertility.

Acknowledgments

Supported in part by the: 1) Midcareer Investigator Award in Women’s Health Research (K24 HD01298); 2) Clinical and Translational Science Awards (UL1 RR024992); 3) Award Numbers TL1 RR024995 from the National Center for Research Resources, a component of the National Institutes of Health(NIH) and NIH Roadmap for Medical Research. The authors do not report any conflicts of interest.

References and recommended reading

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24* Lippman SA, Jones HE, Luppi CG, et al. Home-based self-sampling and self-testing for sexually transmitted infections: acceptable and feasible alternatives to provider-based screening in low-income women in São Paulo, Brazil. Sex Transm Dis. 2007;34:421–428. This study is one of the first to assess home-versus clinic-based STI screening using self-collected vaginal specimens in a developing country. [PubMed]
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