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Cover of Effectiveness, acceptability and cost effectiveness of strategies to improve uptake of STI testing

Effectiveness, acceptability and cost effectiveness of strategies to improve uptake of STI testing

Reducing sexually transmitted infections (STIs)

Evidence review C

NICE Guideline, No. 221

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-4612-9
Copyright © NICE 2022.

1. Effective and cost-effective strategies to improve uptake of STI testing

1.1. Review question

What strategies to improve the uptake of STI testing (excluding HIV testing) are effective and cost-effective?

1.1.1. Introduction

Sexually transmitted infections (STIs) can affect personal wellbeing, mental health and relationships and can also lead to serious health problems including pelvic inflammatory disease, ectopic pregnancy or infertility. STI testing, diagnosis and treatment are central to STI prevention strategies. The purpose of this review is to establish which strategies or interventions for increasing the uptake of STI testing are effective and cost effective.

People can use specialist sexual health services without referral or residence requirements. The number of attendances at these services has increased, and service provision varies. Some clinics have closed or reduced their opening hours. Prevention and targeted outreach services have also been cut. Some clinics have fewer consultants or health advisors, and some patients with STI symptoms report finding it more difficult to get appointments within 48 hours.

Examples of innovative services include online access to STI self-sampling kits with results sent by text message, and being able to make test appointments through the web or a phone app. The National Chlamydia Screening Programme has seen a 22% decrease in tests from 2014 to 2018, but an increase in the proportion of people testing positive over the same time period. The aim of this review is to determine the effectiveness and cost-effectiveness of such strategies.

1.1.2. Summary of the protocol

For the full review protocol see appendix A.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document.

Declarations of interest

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

5,673 references were initially identified from the literature search. 113 quantitative papers were ordered in full-text. Of these, 19 quantitative studies met the inclusion criteria for the effectiveness review as outlined in the review protocol.

1.1.4.2. Excluded studies

Details of excluded studies can be found in appendix J along with reasons for their exclusion.

1.1.5. Summary of studies included in the effectiveness evidence

See appendix D for full evidence tables.

1.1.6. Summary of the effectiveness evidence

Note: 4 studies (Booth 2014, Kang 2012, Dolan 2014 and Niza 2014) reported some outcomes in a way that could be assessed using GRADE. Evidence statements for these findings are included in section 1.1.11.

See appendix F for full GRADE Tables.

1.1.7. Economic evidence

A search for published cost-effectiveness evidence was carried out for this review question. In total, 1,600 records were assessed against eligibility criteria. Of these, 1,506 records were assessed as being ineligible based on disease, intervention and study design and 25 records were excluded based on information in the title and abstract. Two reviewers assessed all the records. The level of agreement between the two reviewers was 100%.

The full-text papers of 69 documents were retrieved and assessed. 59 were excluded, for reasons summarised in Appendix G and further detailed in Appendix J.

1.1.7.1. Included studies

Of the 10 included studies, four were assessed as fully meeting the eligibility criteria and underwent a full data extraction. The remaining six studies partially met the inclusion criteria. Data extraction from these remaining six studies was limited to information that could be used to inform the decision problem. Two reviewers assessed all full-text papers. The level of agreement between the two reviewers was 100%.

The study selection process can be found in Appendix G and the economic evidence tables can be found in Appendix H.

1.1.7.2. Excluded studies

59 full text documents were excluded for this guideline. The documents and the reasons for their exclusion are listed in Appendix J.

1.1.8. Summary of included economic evidence

1.1.9. Economic model

An economic model was developed to assess the cost-effectiveness of offering home self-sampling as a means of STI testing for asymptomatic people. This was chosen as the comparison to model, as the intervention with the best evidence of effectiveness from the quantitative systematic review. A full write up of the economic modelling is provided in appendix I.

1.1.10. Evidence statements

Quantitative

The following evidence was identified, but could not be included in the quantitative analysis due to limitations in the reported data:

  • There is evidence from one further UK RCT on motivation interventions to increase the number of STI tests completed: Booth 2014 (n=253) reported a small but statistically non-significant effect of intervention type on test offer uptake, OR = 1.65 (95% CI 0.70, 3.88) p = .25, with 57.5% of motivational intervention participants accepting the offer of a test compared with 40.2% of standard promotion participants.
  • There is evidence from one further Australian RCT on tailored interventions to increase the number of STI tests completed. Kang 2012 (n=312) reported no statistically significant difference in condom use between the tailored intervention group and the non-tailored intervention group at follow up (p=0.30).
  • There is evidence from two UK RCT on financial incentives to increase the number of STI tests completed. Dolan 2014 (n=2988) reported no statistically significant differences between any incentive types and no statistically significant difference between incentive compared to no incentive. Those receiving a £5 voucher on sample return had the highest rates of return (73.2%) while those receiving an endowment of a £10 voucher had the lowest (67.9%). The non-incentive group had a return rate of 69.4%. Niza 2014 (n=1060) reported a statistically significant difference between incentive and no-incentive: 8.9% return rate for the incentive group, 1.5% return rate for the non-incentive group, z 3.42 (1.16 to 4.28), p<.001. Niza 2014 also reported a statistically significant difference between reward types: 22.8% return rate for vouchers, 2.8% return rate for lottery, z 3.61 (0.54 to 1.82), p<.001

Economic
  • Bracebridge (2012) assessed the cost effectiveness of chlamydia screening using the global dispatch of kits, web-based data collection and test reporting and treatment dispatch by post among 18–24-year olds in the UK. Findings from the analysis showed that the NEEPCT intervention was more costly than the NCSP comparator, with the cost per screening test 1.66 times higher and the cost per positive diagnosis 3.5 times higher. The authors highlighted that the analysis was limited to data on IMD for the predictors of test uptake, as IMD is dependent on postcode any incorrect assignment of a postcode may result in bias analysis. The reviewers highlight that sensitivity analysis was not conducted and that the simplistic costing used does not consider factors such as the cost savings from preventing STI transmission.
  • Jackson (2015) assessed the cost effectiveness of three STI screening promotion interventions for men in football clubs in England. Findings from the analysis suggested that the total costs and average cost per player tested were similar across all interventions and no intervention was judged to be dominant. Sensitivity analysis showed that adjusting the costs associated with each intervention arm subsequently led to a change in the overall cost per player screened for each intervention. The authors highlighted that the uptake of STI testing may have been underestimated as the analysis did not capture additional downstream testing that may have occurred as a result of the intervention. The authors suggested analysing further uncertainties around cost and outcome parameters if a full RCT was conducted. The reviewers highlight that, as the current study was a preliminary economic evaluation, full incremental results were not calculated.
  • Kerry-Barnard (2020) conducted a cost analysis of various uptake scenarios of the Test n Treat screening intervention for chlamydia trachomatis (CT) and neisseria gonorrhoeae (NG). Results showed that higher uptake of the Test n Treat service reduced the cost per screen. The study results suggest that incentivising testing could help increase uptake without reduce positivity rates. The authors highlighted that the study may not be widely applicable and that costs may be higher in other settings and uptake of services may be higher in other settings. The authors also stated that only a small number of students was screened per day which meant that the per student cost was sensitive to changes in the number of students screened per day. The reviewers highlight that full incremental results were not calculated.
  • Looker (2019) assessed the cost effectiveness of six of the most commonly used recall methods for chlamydia retesting for 15–24-year-old GUM clinic attendees. Findings from the analysis showed that the client led no active recall was the most cost-effective, with the cost per retest at £109. Sensitivity analysis showed that adjusting to a longer recall timeframe had a substantial impact on lowering the cost per retest. The authors highlighted that they did not assess the effects of the participant’s demographics such as sexual orientation on retest uptake and therefore cost. The authors suggested that future research may benefit from assessing online testing with automated recall as this is the most likely to be economical.

2. Acceptability of strategies to improve uptake of STI testing

2.1. Review question

What factors influence the acceptability of the strategies used to improve the uptake of STI testing?

2.1.1. Introduction

Data from Public Health England show the overall number of STI diagnoses increased by 5% between 2018 and 2019. STIs can affect personal wellbeing, mental health and relationships and can also lead to serious health problems including pelvic inflammatory disease, ectopic pregnancy or infertility. It is therefore important to address interventions to help prevent or reduce STIs.

STI testing, diagnosis and treatment are central to STI prevention strategies. The purpose of this review is to establish the acceptability of strategies for improving the uptake of STI testing.

2.1.2. Summary of the protocol

For the full review protocol see appendix A.

2.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

2.1.4. Qualitative evidence

2.1.4.1. Included studies

5,673 references were initially identified from the literature search. 40 qualitative papers were ordered in full-text. Of these, 15 qualitative studies met the inclusion criteria for the qualitative review as outlined in the review protocol.

2.1.4.2. Excluded studies

The full list of excluded studies and reasons for exclusion are in appendix J.

2.1.5. Summary of studies included in the qualitative evidence

See table 2.1 for a summary of the study characteristics and appendix D for full evidence tables.

See appendix D for full evidence tables

2.1.6. Summary of themes and sub-themes

Iterative aggregation of codes generated the following key themes and sub-themes

2.1.7. Summary of the qualitative evidence

See appendix F for full GRADE-CERQual tables

3. Integration and discussion of the evidence

3.1. Mixed methods integration

The section headings in this integration are based on the mixed methods questions recommended by the Joanna Briggs Institute manual chapter for mixed methods reviewing.

Are the results/findings from individual syntheses supportive or contradictory?

The effectiveness evidence showed that home testing is effective for increasing the uptake of STI testing and that tailoring of interventions is effective in terms of increasing the number of tests taken and the intention to get tested. It did not find a meaningful difference for a computer assisted interviewing intervention in sexual health clinics.

This evidence is consistent with the finding from the qualitative synthesis. Themes from the synthesis support a preference for remote self-sampling and tailoring of interventions, though the qualitative evidence also highlights the importance of being able to access in-person testing at a sexual health clinic or other venue.

Does the qualitative evidence explain why the intervention is/is not effective?

Themes from the qualitative evidence support the findings of the effectiveness review. The qualitative evidence highlights positive aspects of screening at home such as its convenience and speed. They also highlighted concerns around confidentiality and anonymity in face-to-face services and were concerned that they would be embarrassed or feel judged, especially during face-to-face interviews with a healthcare professional. These themes support the finding that uptake of testing is higher in remote self-sampling interventions because they explain why people might prefer remote tests. They also explain why the in-clinic computer supported interview intervention was not found to be effective – it does not address peoples concerns about embarrassment or feeling judged.

The qualitative evidence provides less support for the effectiveness evidence about tailoring approaches, however the theme about the design and credibility of the intervention highlights that people trust services more if they feel familiar to them and respond to the aesthetics, language and design of interventions. This may explain the relative effectiveness of tailored interventions.

Qualitative finding showed that incentives were useful ways of encouraging people to test, but not necessarily because of the incentive, but because it gave them a reason to test that they could use to justify testing to their peers. The quantitative evidence was sparse and contradictory about the effectiveness of incentive interventions.

Does the qualitative evidence explain differences in the direction and size of effect across the included quantitative studies?

The remote self-sampling interventions vs in-clinic testing showed large amounts of heterogeneity (I2 over 70% in each case). This heterogeneity may be partly explained by qualitative findings about preferences for in-clinic vs remote testing. Qualitative findings report that even though there are many benefits to remote self-sampling, many participants recognised the benefits of being able to attend an in-person appointment, for example to have more confidence in the test results, or, in the case of people with mild learning disabilities, to help them to conduct the test properly. Some participants simply valued the support of a healthcare professional.

Which aspects of the quantitative evidence were/were not explored in the qualitative studies?

The qualitative evidence did not explore the differences found between the secondary outcomes in the quantitative results. Motivational interventions found differences in attitude towards testing but not in intention to test, condom use or contact with a clinician. Tailored interventions found differences in intention to test and contact with a clinician, but not in attitude towards testing or condom use.

Which aspects of the qualitative evidence were/were not tested in the quantitative studies?

The quantitative evidence did not test findings about many of the perceived social norms around STI testing such as the sense of judgment, stigma, or embarrassment, nor did they investigate their participants’ testing preferences or awareness of their STI risk in a quantifiable way. They also did not address the influence of the healthcare workers delivering the interventions or the design and presentation of the interventions, which the qualitative evidence suggested was important. The qualitative data also suggests that there may be gender differences in how people respond to the interventions, but no gender comparisons were explored in the quantitative studies. One of the qualitative papers reported on data from people with mild learning disabilities and their experiences of using remote self-sampling. The quantitative data did not allow sub-grouping of people with learning disabilities to test whether these findings were generalisable. The qualitative evidence also contained a theme about where tests were available and how they could be accessed that was not reflected in the quantitative evidence

3.2. The committee’s discussion and interpretation of the evidence

The qualitative and quantitative reviews are presented as a combined discussion.

3.2.1. The outcomes that matter most

Quantitative evidence

The primary outcome as agreed with the committee in the review protocol was testing uptake. Secondary outcomes discussed were:

  • Changing STI diagnosis rate
  • The number of people at risk who intend to have an STI test
  • Condom use
  • Contact with a clinician regarding sexual health
  • Attitude towards STI testing

The consensus was that the direct measure of testing uptake – the number of tests taken – was the most important outcome, and the discussion about which interventions to use was directed by the findings of it. The committee used the evidence from secondary outcomes to support the main finding but didn’t use the information from them directly as they were derived from fewer studies and were less consistent in the conclusions that could be drawn.

Qualitative evidence

Qualitative outcomes were individual perspectives, experiences, values, beliefs, preferences, views and considerations that influence the acceptability of strategies to increase STI testing uptake. These outcomes covered 8 broad themes:

  • Reasons for testing
  • Accessibility (for people with learning disabilities)
  • Intervention quality and practicalities
  • Design and credibility of the intervention
  • The experience of using the test
  • Confidentiality and stigma
  • Involvement of healthcare professionals
  • Where the tests are available

The qualitative evidence was collected predominantly from younger people, aged 18–35, which may have limited the generalisability to other populations.

3.2.2. The quality of the evidence

The quantitative evidence was rated from moderate to very low confidence using the GRADE criteria: 4 meta-analyses were rated very low and 1 rated low; 2 single study comparisons were rated very low, 4 were rated low and 6 were rated moderate. The evidence for the primary outcome of testing uptake was all rated very low. The committee expressed some concerns about this and there was discussion about why the confidence ratings were not higher: the interventions were grouped into similar approaches but were not identical, therefore there was a lot of heterogeneity; the studies often had issues relating to their risk of bias since it is difficult to blind participants and researchers in these kinds of trial; and many results had large confidence intervals which indicated problems with imprecision. The committee appreciated that the GRADE assessment will give lower scores for this type of evidence as it cannot meet the standards of a classic placebo controlled double blind trial. They felt that the quality should be considered in relative rather than absolute terms for the purposes of interpretation, so did not view very low quality evidence as a barrier to making a recommendation on the interventions which found a statistically significant effect.

The committee were content with the confidence ratings given to the qualitative evidence using the GRADE-CERQUAL criteria. The majority of the 29 sub-themes were rated as high confidence (13 themes) or moderate confidence (11 themes). There were 5 themes rated as low confidence. Themes were downgraded for various reasons in each of the four GRADE-CERQUAL quality domains with either minor or moderate concerns, but with no serious concerns. See appendix F for full details.

The committee noted that the quantitative narrative findings for the use of incentives were contradictory and inconclusive. Niza 2014 supported the use of incentives, but Dolan 2014 found no significant effect of incentives, nor any differences between incentive types (e.g. vouchers, lotteries, donations). The committee did not feel able to base any recommendations on this evidence due to the low quality, but were still interested in exploring the possibility of using incentives as the qualitative evidence supported their use in some contexts.

The quantitative evidence for interventions within clinics showed no effect in a single study. The committee agreed that this was due to the particular intervention, as it was not appropriate to address the issues they were concerned about in this setting.

3.2.3. Benefits and harms

Home testing using self-sampling kits

The committee were satisfied that the evidence supports the use of remote self-sampling kits (where a person collects their own sample for laboratory analysis). The quantitative evidence found significantly higher uptake of STI testing in home self-sampling interventions compared to clinic-based testing. The qualitative evidence also found that self-sampling was well received, provided that the sampling kit is practical, well-designed and accessible. It also indicated that this intervention was beneficial in avoiding issues around stigma and embarrassment that are common in clinic testing. The committee felt that this combination of findings provided a strong justification for recommending this intervention as an alternative to clinic attendance.

The committee agreed that the main benefit would be that it could encourage people who have previously never engaged in services to come forward for testing. However, the demand for these tests is often greater than the supply available and there is a lot of wastage as many kits are not returned. There are also unintended consequences as a result of not having direct clinic contact; the opportunity to diagnose and treat an STI and to initiate partner notification are impaired and rely on the person having the test to take the initiative. They concluded that the benefit of increased uptake would outweigh these downsides, so did not consider them an impediment to recommending this intervention.

There is regional variation in whether home tests are offered and how many are available. In locations that do offer home testing, it still cannot reach everyone who is eligible. In particular, committee members highlighted the self-efficacy needed to access, complete, and return tests and to interpret the results. They also described the specific barriers faced by gender diverse people when answering questions about sex, gender and anatomy to access an appropriate kit. To address this, they recommended ensuring services keep their websites up to date with information on local testing options and to monitor the return rates of kits to check which groups are and are not accessing them. The committee further noted the lack of specific qualitative evidence relating to the experiences and preferences of LGBT+ people in accessing STI testing services, both in clinic and remote, and made a research recommendation about it (see appendix K).

In committee members’ experiences, self-sampling is suitable for chlamydia and gonorrhoea, but less so for other STIs. Tests which require a blood sample, such as syphilis tests, are more challenging to complete so are more likely to be returned in an unsuitable state for analysis. Antibodies from previous infections can also result in false positives that a clinic test would be better able to address. They concluded that self-sampling at home should be part of a suite of testing options and recommended offering it along with in-person attendance at specialist clinics or in primary care, and outreach services based on local needs. In current practice, remote self-sampling is offered only to people who are asymptomatic, so the committee also discussed the potential use of remote self-sampling for appropriate people who have symptoms. It was noted that during the COVID pandemic, some areas had offered remote self-sampling to symptomatic people following telephone triage. The committee were interested in whether this was effective and what the unintended consequences might be, so they made a research recommendation about it (see appendix K).

Tailored interventions

The quantitative evidence showed that individually tailored interventions were effective in increasing testing uptake, whereas motivational interventions without tailoring were not. The committee agreed that this was consistent with previous discussions about cultural competence in targeting interventions to specific groups, so felt confident in recommending this approach. They decided that detailed and specific tailoring used in most of the tailored intervention studies would probably be too resource intensive in practice, so recommended low-level personalisation based on elements of Kang’s (2012) intervention, such as adding names (of patients or healthcare professionals) and demographic-specific information to communications (for example the local rates of STIs in their group). The qualitative evidence did not address tailored interventions, so there was no further information to support the discussion of how to tailor outreach services to specific groups or communities. As a result of this gap in the evidence, the committee made a research recommendation to explore this further. (see appendix K).

Incentives

The committee were interested in the potential of incentives, despite the weakness of the existing quantitative evidence (narrative findings from Niza 2014 and Dolan 2014 which produced conflicting results on whether incentives increased uptake; and were undertaken in specific subpopulations, for example students living in university accommodation in Niaz). They recounted anecdotal evidence of success with voucher schemes in homeless shelters and evidence from other topic areas. Some committee members expressed that vouchers intuitively felt like a better incentive than a lottery, regardless of Dolan 2014 finding no differences in incentive types. They suggested that incentives should not necessarily be disregarded when they seem to work in reality while weaknesses in the design and analysis of the studies may have accounted for the ambiguity of the results.

There were, however, concerns about ethical issues, particularly for those who are financially vulnerable; incentive schemes could constitute a perverse incentive, encouraging people to expose themselves to STI risks in order to be eligible to claim the incentive. The committee agreed that the type of incentive offered is an important consideration. Some committee members suggested non-financial incentives such as virtual badges to indicate STI testing status on dating apps as a way to avoid the potential problems of financial perverse incentives. There are also unintended consequences to STI testing: the procedure itself, taking blood, the risk of false positives, and anxiety while waiting for results. While increased testing is a good thing, excessive or unnecessary testing to gain incentives is not desirable. As there is currently a lack of high quality quantitative evidence to support the use of incentives and little consideration of the possible unintended consequences, the committee made a research recommendation to explore these further (see appendix K)

3.2.4. Cost effectiveness and resource use

The committee noted there were a number of published cost-effectiveness analyses for this review question, which were of reasonable quality and applicability to the UK. However, there were two key limitations that meant they did not feel confident making recommendations directly based off those studies. First, many of the studies looked at issues that would fall within the remit of the National Chlamydia Screening Programme. The committee considered whether those findings could be extrapolated to other STIs or settings, but considered that the existence of the screening programme means services (for those eligible under it) are set up in a somewhat different way to other services, and therefore are not particular generalisable. Other studies looked at very specifically targeted interventions (for example, testing in football clubs) and the committee agreed this was better covered in more general recommendations elsewhere in the guidance about providing a range of services, and targeting to the needs of specific populations, rather than by listing any of these specific individual cases within the recommendations.

The committee made two sets of recommendations from this evidence review. The first set, on tailoring interventions, the committee were confident would not have a significant resource impact, due to the low complexity of the things being recommended. For the second area, on remote self-sampling as a method of STI testing for asymptomatic people, the committee noted that widespread adoption of this would come with significant implications for the restructuring of services, and therefore agreed cost-effectiveness modelling in this area would provide value.

The model built compared a system of solely in clinic STI testing to a system where remote (in particular at home) self-sampling is available. It looked at the benefits of additional identified cases, both for reducing long-term complications in the index-cases identified, and in reducing onward transmission and secondary cases. The analysis covered a range of bacterial STIs (chlamydia, gonorrhoea and syphilis) and looked both at the general population accessing STI testing, and at specific high-risk subgroups (defined by a higher baseline prevalence of STIs).

The modelling found that, assuming self-sampling interventions were as effective in real world settings as in the identified RCTs, offering this as an intervention would be highly cost-effective, with the additional costs generated by the higher volume of tests requested generating considerable additional QALYs, as well as some downstream savings from prevented complications and secondary infections. Data to populate the analysis for the high-risk subgroups was extremely limited, but what was available suggested the intervention would be either approximately equally or most cost-effective in these populations compared to the general population, and therefore the committee were confident in making recommendations covering the whole population, and that these would also be appropriate for these subpopulations.

The committee did note, however, that there were a number of potential risks in widescale implementation of self-sampling that might make it less cost-effective than in trial settings. These would include people requesting and not returning tests, people providing unusable test samples and therefore requiring retesting, and the potential need for confirmatory clinical tests in people with a positive self-sampling test (particular for syphilis testing). Additionally, there is possibility that the availability of self-sampling means lower risk individuals decide to get tested, resulting in a lower test positive rate, reducing the cost-effectiveness of the intervention. The committee noted the impact of these issues will have been captured in the RCT results as far as they happened in those trials, but agreed that in principle there was a risk that the additional information provided and monitoring undertaken during a trial would mean they may not exist to the same extent as when rolled out more widely. A series of sensitivity analyses were conducted (using data from UK routine practice on these factors where available), which showed that when multiple of these more negative assumptions were made simultaneously, there were scenarios in which offering home self-sampling was no longer cost-effective. The committee noted these analyses were likely to be somewhat biased against self-sampling, due to the risk of double counting issues (for example, applying the general UK rate of non-returned tests on top of the unreturned tests already accounted for in the trial), but felt they were still useful as a way of testing the robustness of the conclusions.

The committee considered these findings and decided they were still confident in recommending self-sampling should be available as a testing method. They noted that it was still relatively recently widespread use of these interventions had been made in the UK, and therefore the data at the moment likely reflected teething issues in the setup of services, and improvements were likely as services became more established. Second, they noted that many of these factors were not inevitable results of having a self-sampling service, but rather modifiable parameters that services could look to improve. Therefore, alongside their recommendations that self-sampling be available as a testing methods, they also made implementation recommendations, such as for services to monitor return rates of kits, and to improve the accessibility and usability of those kits, all of which would be expected to improve rates of correct test returns, and therefore improve the cost-effectiveness of the intervention.

The committee noted there had been a considerable increase in remote self-sampling services as a result of the COVID-19 pandemic, but noted in many cases these had been offered instead of in clinic services (with those not being available), rather than as a choice alongside in clinic testing as this guideline recommends as a long-term model. However, this does mean that many services now have increased familiarity with and systems for remote self-sampling, and therefore the implementation barriers to this change should be considerably lower than they would have been if implemented before the onset of the pandemic.

3.2.5. Other factors the committee took into account

The impact of Covid 19 self-sampling

All studies included in the review were conducted prior to the Covid 19 pandemic, so the committee were interested in how people’s behaviour and attitudes may have changed as a result of it. Familiarity and experience with self-swab testing at home will have increased considerably as a result of widespread covid testing, thereby normalising the procedure. In addition, some areas introduced or expanded self-testing for STIs during the pandemic due to service restrictions whereby asymptomatic screening was not available in clinics. Committee members observed that the acceptance of home-testing and self-testing had increased considerably, and that online testing services had been well received during this period. They cautioned, however, that this increase was mainly people who were seeking testing services, rather than reaching people who would not have otherwise come forward for testing. It is also likely that there were some people who declined to use this service if they had wanted an in-clinic test. The committee considered the possibility that a change in acceptance of self-sampling may be short lived if covid becomes less prevalent and noted that frequent covid testing is not directly comparable to frequent STI testing. They made a research recommendation to explore this further (see appendix K).

Informed consent and profiling

Some self-sampling interventions in the quantitative evidence used ‘pop-up’ outreach campaigns to distribute kits to people who may not have sought out testing, particularly targeting hard to reach groups. The committee discussed the ethics and impact of targeting specific demographics for testing and of offering testing to these people in non-clinical settings without fully explaining why it was offered. It was suggested that there may be a lack of informed consent if people are not aware of the implications for themselves and their sexual partners. The qualitative evidence provided a mixture of views on this issue; some found it invasive and inappropriate to be offered testing in this way, while others appreciated the convenience and ease of testing being brought to them. The committee concluded that the opportunity to widen access to testing justified recommending offering self-sampling kits through outreach services.

There were also concerns raised by the qualitative finding that some young people may object to being profiled as high risk, particularly in GP settings where being approached for STI testing could distract from the purpose of their appointment. Similarly, there are also potential issues around pathologising gay, bisexual and other men who have sex with men by profiling them as high risk. Committee members pointed out that it is commonplace in public health to target groups and to profile people who are at higher risk of poor health. For this reason, the focus should be how to offer testing appropriately so that people understand why they have been offered it; they recommended recognising concerns about profiling and addressing the issue with cultural sensitivity and competency The committee further noted that targeting interventions to at-risk groups can also be achieved by making services more accessible, by addressing the needs of trans and gender diverse people, being available in different languages or being available in different formats such as videos targeted at people with learning difficulties.

Types of tests and terminology

Members of the committee explained the distinction between self-sampling (which can either be in clinic or out of clinic), remote self-sampling (where a self-sample is taken at home or in another non-clinical setting and sent for analysis), and home testing (where the sample and test are conducted by the person outside of the clinic). These terms had been used somewhat interchangeably in the evidence so they felt it was important to be clear that the intervention supported by the quantitative evidence was self-sampling at home and the interventions described in the qualitative evidence were self-sampling at home or other non-clinic locations.

There was discussion around what tests are available and appropriate. Although the qualitative evidence indicated that people would prefer a choice about what type of test they are offered and would often prefer a rapid test, this may not be possible in practice. It was pointed out that rapid point of care tests are not yet available for most STIs (they are currently used for HIV). The committee recounted that swabs and urine samples were rarely refused, whereas it can be difficult to persuade people to accept a blood test. This aspect of testing uptake was missing from most of the interventions in the review, so was considered for a research recommendation but not prioritised as the committee preferred to focus on increasing uptake overall. Lastly, it was commented that testing options are not equally effective, for example urine sampling is less sensitive than vulvo-vaginal swab tests for women, therefore offering more choice of testing options may be counter-productive to increasing detection of STIs and should not be recommended.

3.3. Recommendations supported by this, review

This evidence review supports recommendations 1.2.1 to 1.2.9 and the research recommendations on the value of incentives in increasing STI testing, attitudes to remote self-sampling and regular STI testing, the effectiveness and adverse outcomes of self-sampling for people with symptoms, and the experiences of LGBT+ people in accessing STI testing services.

3.4. References – included studies

    3.4.1. Effectiveness

    • Bauermeister, Jose A, Pingel, Emily S, Jadwin-Cakmak, Laura et al (2015) Acceptability and preliminary efficacy of a tailored online HIV/STI testing intervention for young men who have sex with men: the Get Connected! program. AIDS and behavior 19(10): 1860–74 [PMC free article: PMC4522230] [PubMed: 25638038]
    • Booth, Amy R, Norman, Paul, Goyder, Elizabeth et al (2014) Pilot study of a brief intervention based on the theory of planned behaviour and self-identity to increase chlamydia testing among young people living in deprived areas. British journal of health psychology 19(3): 636–51 [PubMed: 24103040]
    • Dolan, Paul and Rudisill, Caroline (2014) The effect of financial incentives on chlamydia testing rates: evidence from a randomized experiment. Social science & medicine (1982) 105: 140–8 [PMC free article: PMC3969100] [PubMed: 24373390]
    • Fuller, Sebastian S, Mercer, Catherine H, Copas, Andrew J et al (2015) The SPORTSMART study: a pilot randomised controlled trial of sexually transmitted infection screening interventions targeting men in football club settings. Sexually transmitted infections 91(2): 106–10 [PMC free article: PMC4345976] [PubMed: 25512674]
    • Kang, Melissa, Rochford, Arlie, Skinner, Rachel et al (2012) Facilitating chlamydia testing among young people: a randomised controlled trial in cyberspace. Sexually transmitted infections 88(8): 568–73 [PubMed: 22764218]
    • Klovstad, Hilde, Natas, Olav, Tverdal, Aage et al (2013) Systematic screening with information and home sampling for genital Chlamydia trachomatis infections in young men and women in Norway: a randomized controlled trial. BMC infectious diseases 13: 30 [PMC free article: PMC3558461] [PubMed: 23343391]
    • Lim, MS, Hocking, JS, Aitken, CK et al (2012) Impact of text and email messaging on the sexual health of young people: a randomised controlled trial. Journal of epidemiology and community health 66(1): 69–74 [PubMed: 21415232]
    • Lustria, Mia Liza A, Cortese, Juliann, Gerend, Mary A et al (2016) A model of tailoring effects: A randomized controlled trial examining the mechanisms of tailoring in a web-based STD screening intervention. Health psychology : official journal of the Division of Health Psychology, American Psychological Association 35(11): 1214–1224 [PubMed: 27441869]
    • Mevissen, Fraukje E F, Ruiter, Robert A C, Meertens, Ree M et al (2011) Justify your love: testing an online STI-risk communication intervention designed to promote condom use and STI-testing. Psychology & health 26(2): 205–21 [PubMed: 21318930]
    • Mortimer, Nathan J, Rhee, Joel, Guy, Rebecca et al (2015) A web-based personally controlled health management system increases sexually transmitted infection screening rates in young people: a randomized controlled trial. Journal of the American Medical Informatics Association : JAMIA 22(4): 805–14 [PubMed: 25773130]
    • Niza, Claudia; Rudisill, Caroline; Dolan, Paul (2014) Vouchers versus Lotteries: What works best in promoting Chlamydia screening? A cluster randomised controlled trial. Applied economic perspectives and policy 36(1): 109–124 [PMC free article: PMC4105573] [PubMed: 25061507]
    • Reagan, Mary M, Xu, Hanna, Shih, Shirley L et al (2012) A randomized trial of home versus clinic-based sexually transmitted disease screening among men. Sexually transmitted diseases 39(11): 842–7 [PMC free article: PMC3476063] [PubMed: 23064532]
    • Richens, J, Copas, A, Sadiq, ST et al (2010) A randomised controlled trial of computer-assisted interviewing in sexual health clinics. Sexually transmitted infections 86(4): 310–314 [PubMed: 20551234]
    • Roth, Alexis M, Van Der Pol, Barbara, Fortenberry, J Dennis et al (2015) The impact of brief messages on HSV-2 screening uptake among female defendants in a court setting: a randomized controlled trial utilizing prospect theory. Journal of health communication 20(2): 230–6 [PMC free article: PMC4356496] [PubMed: 25494832]
    • Smith, Kirsty S, Hocking, Jane S, Chen, Marcus Y et al (2015) Dual Intervention to Increase Chlamydia Retesting: A Randomized Controlled Trial in Three Populations. American journal of preventive medicine 49(1): 1–11 [PubMed: 26094224]
    • van den Broek, Ingrid V F, van Bergen, Jan E A M, Brouwers, Elfi E H G et al (2012) Effectiveness of yearly, register based screening for chlamydia in the Netherlands: controlled trial with randomised stepped wedge implementation. BMJ (Clinical research ed.) 345: e4316 [PMC free article: PMC3390168] [PubMed: 22767614]
    • Wilson, Emma, Free, Caroline, Morris, Tim P et al (2017) Internet-accessed sexually transmitted infection (e-STI) testing and results service: A randomised, single-blind, controlled trial. PLoS medicine 14(12): e1002479 [PMC free article: PMC5744909] [PubMed: 29281628]
    • Wilson, Emma, Leyrat, Clemence, Baraitser, Paula et al (2019) Does internet-accessed STI (e-STI) testing increase testing uptake for chlamydia and other STIs among a young population who have never tested? Secondary analyses of data from a randomised controlled trial. Sexually transmitted infections 95(8): 569–574 [PMC free article: PMC6902059] [PubMed: 31175210]
    • Xu F, Stoner BP, Taylor SN et al (2011) Use of home-obtained vaginal swabs to facilitate rescreening for Chlamydia trachomatis infections: two randomized controlled trials. Obstetrics and gynecology 118(2 Pt 1): 231–239 [PubMed: 21775837]

    3.4.2. Acceptability

    • Aicken, Catherine R H, Fuller, Sebastian S, Sutcliffe, Lorna J et al (2016) Young people’s perceptions of smartphone-enabled self-testing and online care for sexually transmitted infections: qualitative interview study. BMC public health 16: 974 [PMC free article: PMC5022229] [PubMed: 27624633]
    • Estcourt, Claudia, Sutcliffe, Lorna, Mercer, Catherine H et al (2016) No title provided.
    • Fleming, C., Drennan, V.M., Kerry-Barnard, S. et al (2020) Understanding the acceptability, barriers and facilitators for chlamydia and gonorrhoea screening in technical colleges: qualitative process evaluation of the “Test n Treat” trial. BMC public health 20(1): 1212 [PMC free article: PMC7414554] [PubMed: 32770977]
    • Fuller, Sebastian S, Pacho, Agata, Broad, Claire E et al (2019) “It’s not a time spent issue, it’s a ‘what have you spent your time doing?’ issue…” A qualitative study of UK patient opinions and expectations for implementation of Point of Care Tests for sexually transmitted infections and antimicrobial resistance. PloS one 14(4): e0215380 [PMC free article: PMC6467401] [PubMed: 30990864]
    • Gkatzidou, Voula, Hone, Kate, Sutcliffe, Lorna et al (2015) User interface design for mobile-based sexual health interventions for young people: design recommendations from a qualitative study on an online Chlamydia clinical care pathway. BMC medical informatics and decision making 15: 72 [PMC free article: PMC4549868] [PubMed: 26307056]
    • Hogan, Angela H, Howell-Jones, Rebecca S, Pottinger, Elizabeth et al (2010) “…they should be offering it”: a qualitative study to investigate young peoples’ attitudes towards chlamydia screening in GP surgeries. BMC public health 10: 616 [PMC free article: PMC2965724] [PubMed: 20955570]
    • Jackson, Louise, Al-Janabi, Hareth, Roberts, Tracy et al (2021) Exploring young people’s preferences for STI screening in the UK: A qualitative study and discrete choice experiment. Social science & medicine (1982) 279: 113945 [PubMed: 34010779]
    • Jones, Leah Ffion, Ricketts, Ellie, Town, Katy et al (2017) Chlamydia and HIV testing, contraception advice, and free condoms offered in general practice: a qualitative interview study of young adults’ perceptions of this initiative. The British journal of general practice : the journal of the Royal College of General Practitioners 67(660): e490–e500 [PMC free article: PMC5565869] [PubMed: 28533198]
    • Loaring, Jessica, Hickman, Matthew, Oliver, Isabel et al (2013) Could a peer-led intervention increase uptake of chlamydia screening? A proof of principle pilot study. The journal of family planning and reproductive health care 39(1): 21–8 [PubMed: 22855521]
    • Lorimer, Karen and McDaid, Lisa (2013) Young men’s views toward the barriers and facilitators of Internet-based Chlamydia trachomatis screening: qualitative study. Journal of medical Internet research 15(12): e265 [PMC free article: PMC3868974] [PubMed: 24300158]
    • Middleton, Alan, Laidlaw, Rebecca, Pothoulaki, Maria et al (2021) How can we make self-sampling packs for sexually transmitted infections and bloodborne viruses more inclusive? A qualitative study with people with mild learning disabilities and low health literacy. Sexually Transmitted Infections 97(4): 276–281 [PMC free article: PMC8165145] [PubMed: 33906976]
    • Normansell, Rebecca; Drennan, Vari M; Oakeshott, Pippa (2016) Exploring access and attitudes to regular sexually transmitted infection screening: the views of young, multi-ethnic, inner-city, female students. Health expectations : an international journal of public participation in health care and health policy 19(2): 322–30 [PMC free article: PMC5055273] [PubMed: 25703741]
    • Powell, Rachael; Pattison, Helen M; Marriott, John F (2016) Perceptions of Self-Testing for Chlamydia: Understanding and Predicting Self-Test Use. Healthcare (Basel, Switzerland) 4(2) [PMC free article: PMC4934578] [PubMed: 27417613]
    • Richardson, D, Maple, K, Perry, N et al (2010) A pilot qualitative analysis of the psychosocial factors which drive young people to decline chlamydia testing in the UK: implications for health promotion and screening. International journal of STD & AIDS 21(3): 187–90 [PubMed: 20215623]
    • Wayal, Sonali, Llewellyn, Carrie, Smith, Helen et al (2011) Home sampling kits for sexually transmitted infections: preferences and concerns of men who have sex with men. Culture, health & sexuality 13(3): 343–53 [PubMed: 21154069]

    3.4.3. Economic

    • Bracebridge S, Bachmann MO, Ramkhelawon K, Woolnough A. Evaluation of a systematic postal screening and treatment service for genital Chlamydia trachomatis, with remote clinic access via the internet: a cross-sectional study, East of England. Sexually transmitted infections. 2012;88(5):375–81. [PubMed: 22375045]
    • de Wit GA, Over EAB, Schmid BV, van Bergen JEAM, van den Broek IVF, van der Sande MAB, et al Chlamydia screening is not cost-effective at low participation rates: evidence from a repeated register-based implementation study in The Netherlands. Sexually transmitted infections. 2015;91(6):423–9. [PubMed: 25759475]
    • Gillespie P ONCAETKODDBRVDOCECMBMCCF. The cost and cost-effectiveness of opportunistic screening for Chlamydia trachomatis in Ireland. Sexually Transmitted Infections. 2012;88(3):222–8. [PubMed: 22213681]
    • Jackson LJ, Roberts TE, Fuller SS, Sutcliffe LJ, Saunders JM, Copas AJ, et al Exploring the costs and outcomes of sexually transmitted infection (STI) screening interventions targeting men in football club settings: preliminary cost-consequence analysis of the SPORTSMART pilot randomised controlled trial. Sexually transmitted infections. 2015;91(2):100–5. [PMC free article: PMC4345770] [PubMed: 25512670]
    • Kerry-Barnard S, Huntington S, Fleming C, Reid F, Sadiq ST, Drennan VM, et al Near patient chlamydia and gonorrhoea screening and treatment in further education/technical colleges: a cost analysis of the ‘Test n Treat’ feasibility trial. BMC health services research. 2020;20(1):316. [PMC free article: PMC7160983] [PubMed: 32299437]
    • Looker KJ, Buitendam E, Woodhall SC, Hollis E, Ong K-J, Saunders JM, et al Economic evaluation of the cost of different methods of retesting chlamydia positive individuals in England. BMJ open. 2019;9(3):e024828. [PMC free article: PMC6475158] [PubMed: 30904855]
    • Ritchie S, Henley R, Hilton J, Handy R, Ingram J, Mundt S, et al Uptake, yield and resource requirements of screening for asymptomatic sexually transmissible infections among HIV-positive people attending a hospital outpatient clinic. Sexual Health. 2014;11(1):67–72. [PubMed: 24618022]
    • Ross C, Shaw S, Marshall S, Stephen S, Bailey K, Cole R, et al Impact of a social media campaign targeting men who have sex with men during an outbreak of syphilis in Winnipeg, Canada. Canada communicable disease report = Releve des maladies transmissibles au Canada. 2016;42(2):45–9. [PMC free article: PMC5864268] [PubMed: 29770003]
    • Smith KS, Kaldor JM, Hocking JS, Jamil MS, McNulty AM, Read P, et al The acceptability and cost of a home-based chlamydia retesting strategy: findings from the REACT randomised controlled trial. BMC public health. 2016;16:83. [PMC free article: PMC4730759] [PubMed: 26822715]

Appendices

Appendix B. Literature search strategies

Download PDF (111K)

Appendix C. Evidence study selection

Quantitative evidence (PDF, 108K)

Qualitative evidence (PDF, 108K)

Appendix D. Evidence tables

D.1. Effectiveness evidence (PDF, 1022K)

D.2. Qualitative evidence (PDF, 612K)

Appendix E. Forest plotsa

Remote self-sampling kit interventions vs. standard care testing in sexual health clinics (PDF, 261K)

Motivational interventions to increase STI testing (PDF, 120K)

Tailored interventions to increase STI testing (PDF, 123K)

Clinic interventions to increase STI testing (PDF, 109K)

Footnotes

a

Forest plots are only included for outcomes where meta-analysis was undertaken. Outcomes included in single studies do not have forest plots.

Appendix F. GRADE and GRADE-CERQual tables

GRADE tables (PDF, 209K)

GRADE CERQual tables (PDF, 179K)

Appendix G. Economic evidence study selection

Download PDF (149K)

Appendix H. Economic evidence tables

Download PDF (212K)

Appendix I.

Health economic model (PDF, 423K)

References

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Public Health England. Antimicrobial resistance in Neisseria gonorrhoeae in England and Wales. Public Health England,: 2019. Available from: https://assets​.publishing​.service.gov.uk​/government/uploads/system​/uploads/attachment_data​/file/834924​/GRASP__2018_report.pdf.
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National Health Service. Syphilis Symptoms. National Health Service,: 2019. Available from: https://www​.nhs.uk/conditions​/syphilis/symptoms/.
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Public Health England. Sexually transmitted infections and screening for chlamydia in England, 2020. 2020. Available from: https://assets​.publishing​.service.gov.uk​/government/uploads/system​/uploads/attachment_data​/file/914184​/STI_NCSP_report_2019.pdf
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Blomquist PB, Mohammed H, Mikhail A, Weatherburn P, Reid D, Wayal S, et al Characteristics and sexual health service use of MSM engaging in chemsex: results from a large online survey in England. Sex Transm Infect. 2020;96(8):590–95. [PMC free article: PMC7677472] [PubMed: 32139497]
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Price MJ, Ades AE, Soldan K, Welton NJ, Macleod J, Simms I, et al The natural history of Chlamydia trachomatis infection in women: a multi-parameter evidence synthesis. Health Technol Assess. 2016;20(22):1–250. [PMC free article: PMC4819202] [PubMed: 27007215]
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Price MJ, Ades AE, De Angelis D, Welton NJ, Macleod J, Soldan K, et al Risk of pelvic inflammatory disease following Chlamydia trachomatis infection: analysis of prospective studies with a multistate model. Am J Epidemiol. 2013;178(3):484–92. [PMC free article: PMC3727337] [PubMed: 23813703]
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National Health Service. Gonorrhoea - complications. Available from: https://www​.nhs.uk/conditions​/gonorrhoea/complications/
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Public Health England. Sexual and Reproductive Health Return on Investment Tool. 2020
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Marcus JL, Glidden DV, Mayer KH, Liu AY, Buchbinder SP, Amico KR, et al No evidence of sexual risk compensation in the iPrEx trial of daily oral HIV preexposure prophylaxis. PLoS One. 2013;8(12):e81997. [PMC free article: PMC3867330] [PubMed: 24367497]
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Mercer CH, Tanton C, Prah P, Erens B, Sonnenberg P, Clifton S, et al Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). Lancet. 2013;382(9907):1781–94. [PMC free article: PMC3899021] [PubMed: 24286784]
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Glick SN, Morris M, Foxman B, Aral SO, Manhart LE, Holmes KK, et al A comparison of sexual behavior patterns among men who have sex with men and heterosexual men and women. J Acquir Immune Defic Syndr. 2012;60(1):83–90. [PMC free article: PMC3334840] [PubMed: 22522237]
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McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet. 2016;387(10013):53–60. [PMC free article: PMC4700047] [PubMed: 26364263]
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Sadler S, Tosh J, Rawdin A, Squires H, Sutton A, Chilcott J. A model to evaluate the cost effectiveness of condom distribution (CD) schemes, developed for NICE public health guidance on condom distribution schemes and sexually transmitted infections (STIs). 2016. Available from: https://www​.nice.org​.uk/guidance/ng68/documents​/economic-report#page​=20&zoom=100,92,97
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Huntington SE, Burns RM, Harding-Esch E, Harvey MJ, Hill-Tout R, Fuller SS, et al Modelling-based evaluation of the costs, benefits and cost-effectiveness of multipathogen point-of-care tests for sexually transmitted infections in symptomatic genitourinary medicine clinic attendees. BMJ Open. 2018;8(9):e020394. [PMC free article: PMC6144481] [PubMed: 30201794]

Appendix J. Excluded studies

J.1.1. Excluded quantitative studies

StudyCode [Reason]
Ahmad, Fahd A, Jeffe, Donna B, Plax, Katie et al (2014) Computerized self-interviews improve Chlamydia and gonorrhea testing among youth in the emergency department. Annals of emergency medicine 64(4): 376–84 [PMC free article: PMC4156563] [PubMed: 24612901] - Not a relevant study design
Alarcon Gutierrez, Miguel, Fernandez Quevedo, Manuel, Martin Valle, Silvia et al (2018) Acceptability and effectiveness of using mobile applications to promote HIV and other STI testing among men who have sex with men in Barcelona, Spain. Sexually transmitted infections 94(6): 443–448 [PubMed: 29626174] - Not a relevant study design
Baird, Janette and Merchant, Roland C (2014) A randomized controlled trial of the effects of a brief intervention to increase chlamydia and gonorrhea testing uptake among young adult female emergency department patients. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 21(12): 1512–20 [PubMed: 25491714] - Non-UK healthcare setting
Bilardi, Jade E, Fairley, Christopher K, Temple-Smith, Meredith J et al (2010) Incentive payments to general practitioners aimed at increasing opportunistic testing of young women for chlamydia: a pilot cluster randomised controlled trial. BMC public health 10: 70 [PMC free article: PMC2841675] [PubMed: 20158918] - Population are not the target group
Bissessor, Melanie, Fairley, Christopher K, Leslie, David et al (2011) Use of a computer alert increases detection of early, asymptomatic syphilis among higher-risk men who have sex with men. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 53(1): 57–8 [PubMed: 21653303] - Not a relevant study design
Buhrer-Skinner, Monika, Muller, Reinhold, Buettner, Petra G et al (2013) Reducing barriers to testing for Chlamydia trachomatis by mailed self-collected samples. Sexual health 10(1): 32–8 [PubMed: 23158104] - Not a relevant study design
Buhrer-Skinner, Monika, Muller, Reinhold, Buettner, Petra G et al (2011) Improving Chlamydia trachomatis retesting rates by mailed self-collection kit. Sexual health 8(2): 248–50 [PubMed: 21592441] - Not a relevant study design
Bungay, Vicky, Kolar, Kat, Thindal, Soni et al (2013) Community-based HIV and STI prevention in women working in indoor sex markets. Health promotion practice 14(2): 247–55 [PubMed: 22885289] - Not a relevant study design
Cassidy, Christine, Steenbeek, Audrey, Langille, Donald et al (2019) Designing an intervention to improve sexual health service use among university undergraduate students: a mixed methods study guided by the behaviour change wheel. BMC public health 19(1): 1734 [PMC free article: PMC6933635] [PubMed: 31878901] - Not a relevant study design
Chacko, Mariam R, Wiemann, Constance M, Kozinetz, Claudia A et al (2010) Efficacy of a motivational behavioral intervention to promote chlamydia and gonorrhea screening in young women: a randomized controlled trial. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 46(2): 152–61 [PMC free article: PMC2818061] [PubMed: 20113921] - Non-UK healthcare setting
Cheeks, Miyesha A, Fransua, Mesfin, Stringer, Harold G Jr et al (2016) A Quality Improvement Project to Increase Early Detection of Syphilis Infection or Re-infection in HIV-infected Men Who Have Sex With Men. The Journal of the Association of Nurses in AIDS Care : JANAC 27(2): 143–52 [PubMed: 26646978] - Not a relevant study design
Currie, Marian J, Schmidt, Matthias, Davis, Belinda K et al (2010) ‘Show me the money’: financial incentives increase chlamydia screening rates among tertiary students: a pilot study. Sexual health 7(1): 60–5 [PubMed: 20152098] - Not a relevant study design
Dean, Lorraine T, Montgomery, Madeline C, Raifman, Julia et al (2018) The Affordability of Providing Sexually Transmitted Disease Services at a Safety-net Clinic. American journal of preventive medicine 54(4): 552–558 [PMC free article: PMC5860994] [PubMed: 29397280] - Not applicable to a UK context
DiVasta, Amy D, Trudell, Emily K, Francis, Mary et al (2016) Practice-Based Quality Improvement Collaborative to Increase Chlamydia Screening in Young Women. Pediatrics 137(5) [PubMed: 27244777] - Population are not the target group
Dolcini, M Margaret, Harper, Gary W, Boyer, Cherrie B et al (2010) Project ORE: A friendship-based intervention to prevent HIV/STI in urban African American adolescent females. Health education & behavior : the official publication of the Society for Public Health Education 37(1): 115–32 [PMC free article: PMC2922952] [PubMed: 19535612] - Study does not contain a relevant intervention
Downing, Sandra Gaye, Cashman, Colette, McNamee, Heather et al (2013) Increasing chlamydia test of re-infection rates using SMS reminders and incentives. Sexually transmitted infections 89(1): 16–9 [PubMed: 22728911] - Non-UK healthcare setting
Eckman, M.H., Reed, J.L., Trent, M. et al (2020) Cost-effectiveness of Sexually Transmitted Infection Screening for Adolescents and Young Adults in the Pediatric Emergency Department. JAMA Pediatrics [PMC free article: PMC7607492] [PubMed: 33136149] - Population are not the target group
Edelman, Natalie, Cassell, Jackie A, de Visser, Richard et al (2017) Can psychosocial and socio-demographic questions help identify sexual risk among heterosexually-active women of reproductive age? Evidence from Britain’s third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). BMC public health 17(1): 5 [PMC free article: PMC5209946] [PubMed: 28049459] - Not a relevant study design
Ewing, M., Read, P., Knight, V. et al (2013) Do callers to the NSW Sexual Health Infoline attend the services they are referred to?. Sexual Health 10(6): 530–532 [PubMed: 24119390] - Not a relevant study design
Fine, David, Warner, Lee, Salomon, Sarah et al (2017) Interventions to Increase Male Attendance and Testing for Sexually Transmitted Infections at Publicly-Funded Family Planning Clinics. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 61(1): 32–39 [PMC free article: PMC7021216] [PubMed: 28528207] - Not a relevant study design
Forrest, Garry, Boonwaat, Leng, Douglas, Jenny et al (2009) Enhanced chlamydia surveillance in New South Wales (Australia) prisons, 2005–2007. International journal of prisoner health 5(4): 233–40 [PubMed: 25757524] - Not a relevant study design
Friedman, Allison L, Kachur, Rachel E, Noar, Seth M et al (2016) Health Communication and Social Marketing Campaigns for Sexually Transmitted Disease Prevention and Control: What Is the Evidence of their Effectiveness?. Sexually transmitted diseases 43(2suppl1): 83–101 [PubMed: 26779691] - Review article but not a systematic review
Goller, Jane L, Guy, Rebecca J, Gold, Judy et al (2010) Establishing a linked sentinel surveillance system for blood-borne viruses and sexually transmissible infections: methods, system attributes and early findings. Sexual health 7(4): 425–33 [PubMed: 21062582] - Not a relevant study design
Gotz, Hannelore M, Wolfers, Mireille E G, Luijendijk, Ad et al (2013) Retesting for genital Chlamydia trachomatis among visitors of a sexually transmitted infections clinic: randomized intervention trial of home- versus clinic-based recall. BMC infectious diseases 13: 239 [PMC free article: PMC3666896] [PubMed: 23705624] - Comparator in study does not match that specified in protocol
Goyal, Monika K, Fein, Joel A, Badolato, Gia M et al (2017) A Computerized Sexual Health Survey Improves Testing for Sexually Transmitted Infection in a Pediatric Emergency Department. The Journal of pediatrics 183: 147–152e1 [PMC free article: PMC5440080] [PubMed: 28081888] - Non-UK healthcare setting
Graham, Simon, Guy, Rebecca J, Wand, Handan C et al (2015) A sexual health quality improvement program (SHIMMER) triples chlamydia and gonorrhoea testing rates among young people attending Aboriginal primary health care services in Australia. BMC infectious diseases 15: 370 [PMC free article: PMC4557217] [PubMed: 26329123] - Not applicable to a UK context
Graseck, Anna S, Secura, Gina M, Allsworth, Jenifer E et al (2010) Home compared with clinic-based screening for sexually transmitted infections: a randomized controlled trial. Obstetrics and gynecology 116(6): 1311–8 [PMC free article: PMC3120128] [PubMed: 21099596] - Population are not the target group
Graseck, Anna S; Shih, Shirley L; Peipert, Jeffrey F (2011) Home versus clinic-based specimen collection for Chlamydia trachomatis and Neisseria gonorrhoeae. Expert review of anti-infective therapy 9(2): 183–94 [PMC free article: PMC3097250] [PubMed: 21342066] - Review article but not a systematic review
Guy, Rebecca J, Kong, Fabian, Goller, Jane et al (2010) A new national Chlamydia Sentinel Surveillance System in Australia: evaluation of the first stage of implementation. Communicable diseases intelligence quarterly report 34(3): 319–28 [PubMed: 21090187] - Not a relevant study design
Heiligenberg, M., Rijnders, B., Van Der Loeff, M.F.S. et al (2012) High prevalence of sexually transmitted infections in HIV-infected men during routine outpatient visits in the Netherlands. Sexually Transmitted Diseases 39(1): 8–15 [PubMed: 22183837] - Study does not contain a relevant intervention
Hengel, Belinda, Jamil, Muhammad S, Mein, Jacqueline K et al (2013) Outreach for chlamydia and gonorrhoea screening: a systematic review of strategies and outcomes. BMC public health 13: 1040 [PMC free article: PMC3819260] [PubMed: 24188541] - Systematic review contains no relevant studies
Johnson, David; Harrison, Patricia; Sidebottom, Abbey (2010) Providing sexually transmitted disease education and risk assessment to disengaged young men through community outreach. American journal of men’s health 4(4): 305–12 [PubMed: 19706672] - Not a relevant study design
Kettinger, Lindsey Diane (2013) A practice improvement intervention increases chlamydia screening among young women at a women’s health practice. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN 42(1): 81–90 [PubMed: 23181977] - Not a relevant study design
Kmietowicz, Z. (2013) Educating practice staff about chlamydia boosts detection in young adults. BMJ (Online) 347(7925): f5613 [PubMed: 24041706] - Not a peerreviewed publication
Lawton, Beverley A, Rose, Sally B, Elley, C Raina et al (2010) Increasing the uptake of opportunistic chlamydia screening: a pilot study in general practice. Journal of primary health care 2(3): 199–207 [PubMed: 21069115] - Non-UK healthcare setting
Martin, L., Crawford, S., Knight, V. et al (2013) Poor uptake of community based sexually transmissible infection testing at an inner city needle and syringe program. Sexual Health 10(2): 183–184 [PubMed: 23158773] - Not a relevant study design
McNulty, Cliodna A M, Hogan, Angela H, Ricketts, Ellie J et al (2014) Increasing chlamydia screening tests in general practice: a modified Zelen prospective Cluster Randomised Controlled Trial evaluating a complex intervention based on the Theory of Planned Behaviour. Sexually transmitted infections 90(3): 188–94 [PMC free article: PMC3995257] [PubMed: 24005256] - Population are not the target group
Mossenson, A., Algie, K., Olding, M. et al (2012) ‘Yes wee can’ a nurse-driven asymptomatic screening program for chlamydia and gonorrhoea in a remote emergency department. Sexual Health 9(2): 194–195 [PubMed: 22498167] - Not a relevant study design
Nguyen, M.P., Sembajwe, S., Rompalo, A.M. et al (2020) Impacts of STD/HIV Outreach Sites on the Effectiveness of Detecting New Infections in Baltimore City, 2015–2018. Sexually transmitted diseases [PubMed: 32826481] - Not a relevant study design
Nyatsanza, Farai, McSorley, John, Murphy, Siobhan et al (2016) ‘It’s all in the message’: the utility of personalised short message service (SMS) texts to remind patients at higher risk of STIs and HIV to reattend for testing-a repeat before and after study. Sexually transmitted infections 92(5): 393–5 [PubMed: 26670912] - Not a relevant study design
Obafemi, Oluyomi A, Wendel, Karen A, Anderson, Teri S et al (2019) Rapid Syphilis Testing for Men Who Have Sex With Men in Outreach Settings: Evaluation of Test Performance and Impact on Time to Treatment. Sexually transmitted diseases 46(3): 191–195 [PubMed: 30363029] - Study does not contain a relevant intervention
Orozco-Olvera, Victor; Shen, Fuyuan; Cluver, Lucie (2019) The effectiveness of using entertainment education narratives to promote safer sexual behaviors of youth: A meta-analysis, 1985–2017. PloS one 14(2): e0209969 [PMC free article: PMC6372167] [PubMed: 30753185] - No relevant outcomes
Plant, Aaron, Montoya, Jorge A, Rotblatt, Harlan et al (2010) Stop the sores: the making and evaluation of a successful social marketing campaign. Health promotion practice 11(1): 23–33 [PubMed: 18403747] - Not a relevant study design
Ronen, Keshet, Golden, Matthew R, Dombrowski, Julia C et al (2019) Uptake and Impact of Short Message Service Reminders via Sexually Transmitted Infection Partner Services on Human Immunodeficiency Virus/Sexually Transmitted Infection Testing Frequency Among Men Who Have Sex With Men. Sexually transmitted diseases 46(10): 641–647 [PMC free article: PMC6919648] [PubMed: 31517803] - Study does not contain a relevant intervention
Ronen, Keshet, Golden, Matthew R, Dombrowski, Julia C et al (2019) Uptake and Impact of Short Message Service Reminders via STI Partner Services on HIV/STI Testing Frequency among Men Who Have Sex with Men. Sexually transmitted diseases [PMC free article: PMC6919648] [PubMed: 31517803] - Duplicate reference
Rose, Sally B, Lawton, Beverley A, Bromhead, Collette et al (2010) Poor uptake of self-sample collection kits for Chlamydia testing outside primary care. Australian and New Zealand journal of public health 34(5): 517–20 [PubMed: 21040182] - Not a relevant study design
Ross, C, Shaw, S, Marshall, S et al (2016) Impact of a social media campaign targeting men who have sex with men during an outbreak of syphilis in Winnipeg, Canada. Canada communicable disease report = Releve des maladies transmissibles au Canada 42(2): 45–49 [PMC free article: PMC5864268] [PubMed: 29770003] - Not a relevant study design
Roth, Alexis M, Goldshear, Jesse L, Martinez-Donate, Ana P et al (2016) Reducing Missed Opportunities: Pairing Sexually Transmitted Infection Screening With Syringe Exchange Services. Sexually transmitted diseases 43(11): 706–708 [PubMed: 27893601] - Study does not contain a relevant intervention
Sagor, Rachel S, Golding, Jeremy, Giorgio, Margaret M et al (2016) Power of Knowledge: Effect of Two Educational Interventions on Readiness for Chlamydia Screening. Clinical pediatrics 55(8): 717–23 [PubMed: 26350429] - Population are not the target group
Ten Hoor, Gill, Hoebe, Christian Jpa, van Bergen, Jan Eam et al (2014) The influence of two different invitation letters on Chlamydia testing participation: randomized controlled trial. Journal of medical Internet research 16(1): e24 [PMC free article: PMC3936267] [PubMed: 24480721] - Non-UK healthcare setting
Tuite, Ashleigh R, McCabe, Caitlin J, Ku, Jennifer et al (2011) Projected cost-savings with herpes simplex virus screening in pregnancy: towards a new screening paradigm. Sexually transmitted infections 87(2): 141–8 [PubMed: 21097810] - Population are not the target group
van Bergen, Jan E A M, Fennema, Johannes S A, van den Broek, Ingrid V F et al (2010) Rationale, design, and results of the first screening round of a comprehensive, register-based, Chlamydia screening implementation programme in the Netherlands. BMC infectious diseases 10: 293 [PMC free article: PMC2959064] [PubMed: 20925966] - Comparator in study does not match that specified in protocol
van den Broek, Ingrid V F, Hoebe, Christian J P A, van Bergen, Jan E A M et al (2010) Evaluation design of a systematic, selective, internet-based, Chlamydia screening implementation in the Netherlands, 2008–2010: implications of first results for the analysis. BMC infectious diseases 10: 89 [PMC free article: PMC2858140] [PubMed: 20374635] - Duplicate reference
Walker, Jennifer, Fairley, Christopher K, Walker, Sandra M et al (2010) Computer reminders for Chlamydia screening in general practice: a randomized controlled trial. Sexually transmitted diseases 37(7): 445–50 [PubMed: 20375930] - Non-UK healthcare setting
Ward, James, Guy, Rebecca J, Rumbold, Alice R et al (2019) Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial. The Lancet. Global health 7(11): e1553–e1563 [PubMed: 31607467] - Not applicable to a UK context
Wilson, David P, Heymer, Kelly-Jean, Anderson, Jonathan et al (2010) Sex workers can be screened too often: a cost-effectiveness analysis in Victoria, Australia. Sexually transmitted infections 86(2): 117–25 [PubMed: 19843534] - Not applicable to a UK context
Wong, William Chi Wai, Lau, Stephanie Tsz Hei, Choi, Edmond Pui Hang et al (2019) A Systematic Literature Review of Reviews on the Effectiveness of Chlamydia Testing. Epidemiologic reviews 41(1): 168–175 [PubMed: 31565737] - Review article but not a systematic review
Yao, Patricia, Fu, Rongwei, Craig Rushing, Stephanie et al (2018) Texting 4 Sexual Health: Improving Attitudes, Intention, and Behavior Among American Indian and Alaska Native Youth. Health promotion practice 19(6): 833–843 [PubMed: 29557176] - Not applicable to a UK context
Zenner, Dominik, Molinar, Darko, Nichols, Tom et al (2012) Should young people be paid for getting tested? A national comparative study to evaluate patient financial incentives for chlamydia screening. BMC public health 12: 261 [PMC free article: PMC3350390] [PubMed: 22471791] - Not a relevant study design
Zhang, Qinya, Huhn, Kim J, Tan, Andy et al (2017) “Testing is Healthy” TimePlay campaign: Evaluation of sexual health promotion gamification intervention targeting young adults. Canadian journal of public health = Revue canadienne de sante publique 108(1): e85–e90 [PMC free article: PMC6972345] [PubMed: 28425904] - Not a relevant study design
Zou, Huachun, Fairley, Christopher K, Guy, Rebecca et al (2013) Automated, computer generated reminders and increased detection of gonorrhoea, chlamydia and syphilis in men who have sex with men. PloS one 8(4): e61972 [PMC free article: PMC3629129] [PubMed: 23613989] - Not a relevant study design
Zou, Huachun, Fairley, Christopher K, Guy, Rebecca et al (2012) The efficacy of clinic-based interventions aimed at increasing screening for bacterial sexually transmitted infections among men who have sex with men: a systematic review. Sexually transmitted diseases 39(5): 382–7 [PubMed: 22504605] - Systematic review contains no relevant studies

J.1.2. Excluded qualitative studies

StudyCode [Reason]
Buston, Katie and Wight, Daniel (2010) Self-reported sexually transmitted infection testing behaviour amongst incarcerated young male offenders: findings from a qualitative study. The journal of family planning and reproductive health care 36(1): 7–11 [PubMed: 20067666] - Does not refer to an intervention
Cassidy, Christine, Steenbeek, Audrey, Langille, Donald et al (2019) Designing an intervention to improve sexual health service use among university undergraduate students: a mixed methods study guided by the behaviour change wheel. BMC public health 19(1): 1734 [PMC free article: PMC6933635] [PubMed: 31878901] - Does not contain qualitative data
Cook, Catherine (2011) ‘About as comfortable as a stranger putting their finger up your nose’: speculation about the (extra)ordinary in gynaecological examinations. Culture, health & sexuality 13(7): 767–80 [PubMed: 21656407] - Study was not conducted in the UK
Dang, Michelle T, Amos, Aaron, Dangerfield, Monique et al (2019) A Youth Participatory Project to Address STIs and HIV among Homeless Youth. Comprehensive child and adolescent nursing 42(3): 222–240 [PubMed: 29902090] - Study was not conducted in the UK
Freeman, Elaine, Howell-Jones, Rebecca, Oliver, Isabel et al (2009) Promoting chlamydia screening with posters and leaflets in general practice–a qualitative study. BMC public health 9: 383 [PMC free article: PMC2766388] [PubMed: 19821964] - Population are not service users
Hsieh, Y.-H., Lewis, M.K., Viertel, V.G. et al (2020) Performance evaluation and acceptability of point-of-care Trichomonas vaginalis testing in adult female emergency department patients. International Journal of STD and AIDS [PMC free article: PMC7785123] [PubMed: 32998638] - Does not contain qualitative data
Jafari, Yalda, Johri, Mira, Joseph, Lawrence et al (2014) Poor Reporting of Outcomes Beyond Accuracy in Point-of-Care Tests for Syphilis: A Call for a Framework. AIDS research and treatment 2014: 465932 [PMC free article: PMC3985157] [PubMed: 24795821] - Does not contain qualitative data
Kricka, L.J. and Price, C.P. (2009) Public opinion and experience of point-of-care testing: Results of a small pilot survey. Point of Care 8(4): 160–163 - Does not contain qualitative data
Llewellyn, Carrie, Pollard, Alex, Smith, Helen et al (2009) Are home sampling kits for sexually transmitted infections acceptable among men who have sex with men?. Journal of health services research & policy 14(1): 35–43 [PubMed: 19103915] - Published before 2010
Lorimer, K; Reid, M E; Hart, G J (2009) “It has to speak to people’s everyday life…”: qualitative study of men and women’s willingness to participate in a non-medical approach to Chlamydia trachomatis screening. Sexually transmitted infections 85(3): 201–5 [PubMed: 19106148] - Published before 2010
McDonagh, L.K., Harwood, H., Saunders, J.M. et al (2020) How to increase chlamydia testing in primary care: a qualitative exploration with young people and application of a meta-theoretical model. Sexually transmitted infections [PMC free article: PMC7677464] [PubMed: 32471931] - Does not refer to an int ervention
Pittman, Ellen, Purcell, Hillary, Dize, Laura et al (2018) Acceptability and feasibility of self-sampling for the screening of sexually transmitted infections in cabana privacy shelters. International journal of STD & AIDS 29(5): 461–465 [PMC free article: PMC6055996] [PubMed: 28959922] - Study was not conducted in the UK
Reed, Jennifer L, Punches, Brittany E, Taylor, Regina G et al (2017) A Qualitative Analysis of Adolescent and Caregiver Acceptability of Universally Offered Gonorrhea and Chlamydia Screening in the Pediatric Emergency Department. Annals of emergency medicine 70(6): 787–796e2 [PMC free article: PMC6894612] [PubMed: 28559031] - Study was not conducted in the UK
Roth, A M, Rosenberger, J G, Reece, M et al (2013) Expanding sexually transmitted infection screening among women and men engaging in transactional sex: the feasibility of field-based self-collection. International journal of STD & AIDS 24(4): 323–8 [PMC free article: PMC3970701] [PubMed: 23970665] - Study was not conducted in the UK
Roth, Alexis M, Rosenberger, Joshua G, Reece, Michael et al (2012) A methodological approach to improve the sexual health of vulnerable female populations: incentivized peer-recruitment and field-based STD testing. Journal of health care for the poor and underserved 23(1): 367–75 [PubMed: 22643484] - Study was not conducted in the UK
Roth, Alexis, Van Der Pol, Barbara, Dodge, Brian et al (2011) Future chlamydia screening preferences of men attending a sexually transmissible infection clinic. Sexual health 8(3): 419–26 [PubMed: 21851785] - Study was not conducted in the UK
Shoveller, Jean A, Knight, Rod, Johnson, Joy et al (2010) ‘Not the swab!’ Young men’s experiences with STI testing. Sociology of health & illness 32(1): 57–73 [PubMed: 20415807] - Study was not conducted in the UK
Sun, Christina J, Stowers, Jason, Miller, Cindy et al (2015) Acceptability and feasibility of using established geosocial and sexual networking mobile applications to promote HIV and STD testing among men who have sex with men. AIDS and behavior 19(3): 543–52 [PMC free article: PMC4359067] [PubMed: 25381563] - Study was not conducted in the UK
Tobin, Karin, Edwards, Catie, Flath, Natalie et al (2018) Acceptability and feasibility of a Peer Mentor program to train young Black men who have sex with men to promote HIV and STI home-testing to their social network members. AIDS care 30(7): 896–902 [PMC free article: PMC6338070] [PubMed: 29482342] - Study was not conducted in the UK
Widdice, Lea E, Hsieh, Yu-Hsiang, Silver, Barbara et al (2018) Performance of the Atlas Genetics Rapid Test for Chlamydia trachomatis and Women’s Attitudes Toward Point-Of-Care Testing. Sexually transmitted diseases 45(11): 723–727 [PMC free article: PMC6179923] [PubMed: 29771869] - Study was not conducted in the UK

J.1.3. Excluded economic studies

ReferenceReason for exclusion
Adams EJ, Ehrlich A, Turner KME, Shah K, Macleod J, Goldenberg S, et al Mapping patient pathways and estimating resource use for point of care versus standard testing and treatment of chlamydia and gonorrhoea in genitourinary medicine clinics in the UK. BMJ open. 2014;4(7):e005322. [PMC free article: PMC4120370] [PubMed: 25056977] Wrong study design
Anonymous. Corrigendum to “Syphilis Screening: A Review of the Syphilis Health Check Rapid Immunochromatographic Test” (Journal of Pharmacy Technology, 33, 2, (53–59), 10.177/8755122517691308). Journal of Pharmacy Technology. 2020;36(2):91. [PMC free article: PMC7047244] [PubMed: 34752533] Systematic review
Atherly A, Blake SC. Efforts by commercial health plans to increase Chlamydia trachomatis screening among their members. Sexually transmitted diseases. 2013;40(1):55–60. [PubMed: 23254117] Wrong study design
Bennett C, Knight V, Knox D, Gray J, Hartmann G, McNulty A. An alternative model of sexually transmissible infection testing in men attending a sex-on-premises venue in Sydney: A cross-sectional descriptive study. Sexual Health. 2016;13(4):353–8. [PubMed: 27208975] Wrong outcomes
Bernstein KT, Chow JM, Pathela P, Gift TL. Bacterial Sexually Transmitted Disease Screening Outside the Clinic–Implications for the Modern Sexually Transmitted Disease Program. Sexually transmitted diseases. 2016;43(2suppl1):42–52. [PMC free article: PMC5583631] [PubMed: 26779687] Systematic review
Bissessor L, Wilson J, McAuliffe G, Upton A. Audit of Trichomonas vaginalis test requesting by community referrers after a change from culture to molecular testing, including a cost analysis. The New Zealand medical journal. 2017;130(1457):34–7. [PubMed: 28617786] Wrong intervention
Blake DR, Spielberg F, Levy V, Lensing S, Wolff PA, Venkatasubramanian L, et al Could home sexually transmitted infection specimen collection with e-prescription be a cost-effective strategy for clinical trials and clinical care? Sexually Transmitted Diseases. 2015;42(1):13–9. [PMC free article: PMC4276035] [PubMed: 25504295] Wrong setting
Borkent-Raven BA, Janssen MP, van der Poel CL, Bonsel GJ, van Hout BA. Cost-effectiveness of additional blood screening tests in the Netherlands. Transfusion. 2012;52(3):478–88. [PubMed: 21880046] Wrong intervention
Bristow CC, Larson E, Javanbakht M, Huang E, Causer L, Klausner JD. A review of recent advances in rapid point-of-care tests for syphilis. Sexual Health. 2015;12(2):119–25. [PubMed: 25622292] Systematic review
Chadwick RC, McGregor K, Sneath P, Rempel J, He BLQ, Brown A, et al STI initiative: Improving testing for sexually transmitted infections in women. BMJ open quality. 2018;7(4):e000461. [PMC free article: PMC6203025] [PubMed: 30397665] Wrong study design
Chesson HW, Bernstein KT, Gift TL, Marcus JL, Pipkin S, Kent CK. The cost-effectiveness of screening men who have sex with men for rectal chlamydial and gonococcal infection to prevent HIV Infection. Sexually transmitted diseases. 2013;40(5):366–71. [PMC free article: PMC6745689] [PubMed: 23588125] Wrong outcomes
Currie MJ, Schmidt M, Davis BK, Baynes AM, O’Keefe EJ, Bavinton TP, et al ‘Show me the money’: financial incentives increase chlamydia screening rates among tertiary students: a pilot study. Sexual health. 2010;7(1):60–5. [PubMed: 20152098] Wrong outcomes
Currie MJ, Deeks LS, Cooper GM, Martin SJ, Parker RM, Del Rosario R, et al Community pharmacy and cash reward: A winning combination for chlamydia screening? Sexually Transmitted Infections. 2013;89(3):212–6. [PubMed: 23093739] Wrong outcomes
Das BB, Ronda J, Trent M. Pelvic inflammatory disease: Improving awareness, prevention, and treatment. Infection and Drug Resistance. 2016;9:191–7. [PMC free article: PMC4998032] [PubMed: 27578991] Systematic review
Desai M, Woodhall SC, Nardone A, Burns F, Mercey D, Gilson R. Active recall to increase HIV and STI testing: a systematic review. Sexually transmitted infections. 2015;91(5):314–23. [PubMed: 25759476] Systematic review
Eaton EF, Hudak K, Muzny CA. Budgetary Impact of Compliance With STI Screening Guidelines in Persons Living With HIV. Journal of acquired immune deficiency syndromes (1999). 2017;74(3):303–8. [PMC free article: PMC5303178] [PubMed: 27787348] Wrong study design
Eaton EF, Joe W, Kilgore ML, Muzny CA. Reverse syphilis screening algorithm fails to demonstrate cost effectiveness in persons living with HIV. International journal of STD & AIDS. 2018;29(6):563–7. [PMC free article: PMC6025800] [PubMed: 29173098] Wrong outcomes
Estcourt C, Sutcliffe L, Mercer CH, Copas A, Saunders J, Roberts TE, et al No title provided. 2016. [PubMed: 27997089] Systematic review
Friedman AL, Bozniak A, Ford J, Hill A, Olson K, Ledsky R, et al Reaching Youth With Sexually Transmitted Disease Testing: Building on Successes, Challenges, and Lessons Learned From Local Get Yourself Tested Campaigns. Social marketing quarterly. 2014;20(2):116–38. [PMC free article: PMC6866650] [PubMed: 31749662] Wrong outcomes
Frost JJ, Sonfield A, Zolna MR, Finer LB. Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program. The Milbank quarterly. 2014;92(4):696–749. [PMC free article: PMC4266172] [PubMed: 25314928] Wrong intervention
Gamage DG, Fuller CA, Cummings R, Tomnay JE, Chung M, Chen M, et al Advertising sexual health services that provide sexually transmissible infection screening for rural young people - what works and what doesn’t. Sexual health. 2011;8(3):407–11. [PubMed: 21851783] Wrong outcomes
Gliddon HD, Peeling RW, Kamb ML, Toskin I, Wi TE, Taylor MM. A systematic review and meta-analysis of studies evaluating the performance and operational characteristics of dual point-of-care tests for HIV and syphilis. Sexually transmitted infections. 2017;93(s4):3–s15. [PMC free article: PMC6754342] [PubMed: 28747410] Systematic review
Guerrero EG, Cederbaum JA. Adoption and utilization of sexually transmitted infections testing in outpatient substance abuse treatment facilities serving high risk populations in the U.S. The International journal on drug policy. 2011;22(1):41–8. [PMC free article: PMC3031721] [PubMed: 20970314] Wrong outcomes
Habel MA, Haderxhanaj L, Hogben M, Eastman-Mueller H, Chesson H, Roberts CM. Does your College Campus GYT? Evaluating the Effect of a Social Marketing Campaign Designed to Raise STI Awareness and Encourage Testing. Cases in public health communication and marketing. 2015;8:51–70. [PMC free article: PMC6866652] [PubMed: 31749899] Wrong setting
Herbst de Cortina S, Bristow CC, Joseph Davey D, Klausner JD. A Systematic Review of Point of Care Testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Infectious diseases in obstetrics and gynecology. 2016;2016:4386127. [PMC free article: PMC4899593] [PubMed: 27313440] Systematic review
Hislop J, Quayyum Z, Flett G, Boachie C, Fraser C, Mowatt G. Systematic review of the clinical effectiveness and cost-effectiveness of rapid point-of-care tests for the detection of genital chlamydia infection in women and men. Health technology assessment (Winchester, England). 2010;14(29):1–iv. [PubMed: 20557810] Systematic review
Hocking JS, Donovan B, Guy R. Matters Arising: Over 150 potentially low-value health care practices: an Australian study. Med J Aust. 2013;198(2):83–4. [PubMed: 23373488] Wrong study design
Huang W, Gaydos CA, Barnes MR, Jett-Goheen M, Blake DR. Cost-effectiveness analysis of Chlamydia trachomatis screening via internet-based self-collected swabs compared with clinic-based sample collection. Sexually transmitted diseases. 2011;38(9):815–20. [PMC free article: PMC3156983] [PubMed: 21844736] Wrong outcomes
Huang W, Gaydos CA, Barnes MR, Jett-Goheen M, Blake DR. Comparative effectiveness of a rapid point-of-care test for detection of Chlamydia trachomatis among women in a clinical setting. Sexually transmitted infections. 2013;89(2):108–14. [PMC free article: PMC3671871] [PubMed: 22984085] Wrong intervention
Hull S, Kelley S, Clarke JL. Sexually Transmitted Infections: Compelling Case for an Improved Screening Strategy. Population health management. 2017;20(s1):1–s11. [PubMed: 28920768] Systematic review
Huntington SE, Burns RM, Harding-Esch E, Harvey MJ, Hill-Tout R, Fuller SS, et al Modelling-based evaluation of the costs, benefits and cost-effectiveness of multipathogen point-of-care tests for sexually transmitted infections in symptomatic genitourinary medicine clinic attendees. BMJ open. 2018;8(9):e020394. [PMC free article: PMC6144481] [PubMed: 30201794] Wrong intervention
Jenkins WD, Rabins C, Barnes M, Agreda P, Gaydos C. Use of the internet and self-collected samples as a sexually transmissible infection intervention in rural Illinois communities. Sexual health. 2011;8(1):79–85. [PubMed: 21371388] Wrong setting
Jenkins WD, Zahnd W, Kovach R, Kissinger P. Chlamydia and gonorrhea screening in United States emergency departments. The Journal of emergency medicine. 2013;44(2):558–67. [PubMed: 23102593] Systematic review
Kanga I, Williams D, Hatchette T, MacKinnon SB, Jung H, Black C, et al No title provided. 2018. [PubMed: 31145563] Systematic review
Kelly C, Johnston J, Carey F. Evaluation of a partnership between primary and secondary care providing an accessible Level 1 sexual health service in the community. International journal of STD & AIDS. 2014;25(10):751–7. [PubMed: 24469970] Wrong intervention
Kennedy CE, Spaulding AB, Brickley DB, Almers L, Mirjahangir J, Packel L, et al Linking sexual and reproductive health and HIV interventions: A systematic review. Journal of the International AIDS Society. 2010;13(1):26. [PMC free article: PMC2918569] [PubMed: 20642843] Systematic review
Knight V, Ryder N, Guy R, Lu H, Wand H, McNulty A. New Xpress sexually transmissible infection screening clinic improves patient journey and clinic capacity at a large sexual health clinic. Sexually transmitted diseases. 2013;40(1):75–80. [PubMed: 23250305] Wrong intervention
Lewis FM, Schillinger JA, Taylor M, Brewer TH, Blank S, Mickey T, et al Needle in a haystack: the yield of syphilis outreach screening at 5 US sites-2000 to 2007. Journal of public health management and practice : JPHMP. 2011;17(6):513–21. [PMC free article: PMC6785748] [PubMed: 21964362] Wrong setting
Malaysian Health Technology A. Point-Of-Care test for Chlamydia. Putrajaya: Malaysian Health Technology Assessment (MaHTAS). 2012. Systematic review
Nelson Hd ZBCADMPM. Screening for gonorrhea and chlamydia: systematic review to update the U.S. Preventive Services Task Force Recommendations. Agency for Healthcare Research and Quality (AHRQ). 2014. [PubMed: 25356451] Systematic review
Niza C, Rudisill C, Dolan P. Vouchers versus Lotteries: What Works Best in Promoting Chlamydia Screening? A Cluster Randomized Controlled Trial. Applied Economic Perspectives and Policy. 2014;36(1):109–24. [PMC free article: PMC4105573] [PubMed: 25061507] Wrong study design
Orozco-Olvera V, Shen F, Cluver L. The effectiveness of using entertainment education narratives to promote safer sexual behaviors of youth: A meta-analysis, 1985–2017. PloS one. 2019;14(2):e0209969. [PMC free article: PMC6372167] [PubMed: 30753185] Systematic review
Owusu-Edusei K PTABRC. Serologic testing for syphilis in the United States: a cost-effectiveness analysis of two screening algorithms. Sexually Transmitted Diseases. 2011;38(1):1–7. [PubMed: 20739911] Wrong study design
Owusu-Edusei K, Jr., Hoover KW, Gift TL. Cost-Effectiveness of Opt-Out Chlamydia Testing for High-Risk Young Women in the U.S. American journal of preventive medicine. 2016;51(2):216–24. [PMC free article: PMC6785744] [PubMed: 26952078] Wrong setting
Page C, Mounsey A, Rowland K. Is self-swabbing for STIs a good idea? Journal of Family Practice. 2013;62(11):651–3. [PMC free article: PMC3948498] [PubMed: 24288710] Wrong study design
Palmer MJ, Henschke N, Villanueva G, Maayan N, Bergman H, Glenton C, et al Targeted client communication via mobile devices for improving sexual and reproductive health. Cochrane Database of Systematic Reviews. 2020;2020(8):cd013680. [PMC free article: PMC8409381] [PubMed: 32779730] Systematic review
Peterman TA, Fakile YF. What Is the Use of Rapid Syphilis Tests in the United States? Sex Transm Dis. 2016;43(3):201–3. [PMC free article: PMC6752880] [PubMed: 26859809] Systematic review
Read PJ, Knight V, Bourne C, Guy R, Donovan B, Allan W, et al Community event-based outreach screening for syphilis and other sexually transmissible infections among gay men in Sydney, Australia. Sexual health. 2013;10(4):357–62. [PubMed: 23806620] Wrong outcomes
Rukh S, Khurana R, Mickey T, Anderson L, Velasquez C, Taylor M. Chlamydia and gonorrhea diagnosis, treatment, personnel cost savings, and service delivery improvements after the implementation of express sexually transmitted disease testing in Maricopa County, Arizona. Sexually transmitted diseases. 2014;41(1):74–8. [PMC free article: PMC6749604] [PubMed: 24326585] Wrong setting
Shih SL, Graseck AS, Secura GM, Peipert JF. Screening for sexually transmitted infections at home or in the clinic? Current opinion in infectious diseases. 2011;24(1):78–84. [PMC free article: PMC3125396] [PubMed: 21124216] Systematic review
Taylor MM, Frasure-Williams J, Burnett P, Park IU. Interventions to Improve Sexually Transmitted Disease Screening in Clinic-Based Settings. Sexually transmitted diseases. 2016;43(2suppl1):28–41. [PMC free article: PMC6751565] [PubMed: 26779685] Systematic review
Turner K, Adams E, Grant A, Macleod J, Bell G, Clarke J, et al Costs and cost effectiveness of different strategies for chlamydia screening and partner notification: an economic and mathematical modelling study. BMJ (Clinical research ed). 2011;342:c7250. [PubMed: 21205807] Wrong outcomes
Turner KME, Round J, Horner P, Macleod J, Goldenberg S, Deol A, et al An early evaluation of clinical and economic costs and benefits of implementing point of care NAAT tests for Chlamydia trachomatis and Neisseria gonorrhoea in genitourinary medicine clinics in England. Sexually transmitted infections. 2014;90(2):104–11. [PMC free article: PMC3932743] [PubMed: 24273127] Wrong outcomes
Turner KME, Looker KJ, Syred J, Zienkiewicz A, Baraitser P. Online testing for sexually transmitted infections: A whole systems approach to predicting value. plos one. 2019;14(2):e0212420. [PMC free article: PMC6386384] [PubMed: 30794589] Wrong outcomes
van Bergen JEAM, Fennema JSA, van den Broek IVF, Brouwers EEHG, de Feijter EM, Hoebe CJPA, et al Rationale, design, and results of the first screening round of a comprehensive, register-based, Chlamydia screening implementation programme in the Netherlands. BMC infectious diseases. 2010;10:293. [PMC free article: PMC2959064] [PubMed: 20925966] Wrong outcomes
Verougstraete N, Verbeke V, De Canniere AS, Simons C, Padalko E, Coorevits L. To pool or not to pool? Screening of Chlamydia trachomatis and Neisseria gonorrhoeae in female sex workers: Pooled versus single-site testing. Sexually Transmitted Infections. 2020;96(6):417–21. [PubMed: 32404400] Wrong outcomes
Wilson DP, Heymer K-J, Anderson J, O’Connor J, Harcourt C, Donovan B. Sex workers can be screened too often: a cost-effectiveness analysis in Victoria, Australia. Sexually transmitted infections. 2010;86(2):117–25. [PubMed: 19843534] Wrong study design
Wong WCW, Lau STH, Choi EPH, Tucker JD, Fairley CK, Saunders JM. A Systematic Literature Review of Reviews on the Effectiveness of Chlamydia Testing. Epidemiologic reviews. 2019;41(1):168–75. [PubMed: 31565737] Systematic review
Zhang Q, Huhn KJ, Tan A, Douglas RE, Li HG, Murti M, et al “Testing is Healthy” TimePlay campaign: Evaluation of sexual health promotion gamification intervention targeting young adults. Canadian journal of public health = Revue canadienne de sante publique. 2017;108(1):e85–e90. [PMC free article: PMC6972345] [PubMed: 28425904] Wrong outcomes

Appendix K. Research recommendations – full details

K.1.1. Research recommendation (PDF, 155K)

Tables

Table 1PICO inclusion criteria

Eligibility criteriaContent
Population

Sexually active people from age 16.

This will include younger people who contact or use sexual health services and are considered to be Gillick competent and satisfies the Fraser guidelines (able to consent)

Interventions

Interventions or strategies that have a stated primary aim of improving the uptake of STI testing (excluding HIV testing), including but not limited to:

Healthcare settings

  • Opportunistic STI testing during healthcare consultations that are not specifically related to sexual health
  • Opportunistic testing within reproductive health and termination of pregnancy services
  • STI point of care tests, including rapid turnaround diagnostics
  • Education based interventions
  • Email invites for testing
  • Text messaging invites for testing
  • Changes in service provision and delivery that may improve access to sexual health services and testing accessibility such as reduced waiting times, extended clinic opening hours, walk-in clinics, short notice appointments, appointment booking systems, and whether services meet ‘You’re Welcome’ youth friendly quality criteria.
  • Testing services delivered in spoke or satellite clinics.
  • Remote service delivery or telephone and/or video consultations (e.g. Skype, GP at Hand, PushDoctor, Dr Thom)

Non healthcare settings

  • Online testing services
  • STI self-sampling and/or self-testing kits
  • Testing services delivered in non-clinical community settings such as voluntary or community organisations or in prisons
  • Testing services delivered in outreach settings such as bars, clubs, faith-based settings, saunas, sex on premises venues
  • Social media invites or advertisements for STI testing (including dating apps and ‘influencers’)

Comparator
  • Another intervention
  • No intervention
OutcomesPrimary outcomes
  • Uptake of STI testing
Secondary outcomes
  • Safety or adverse effects
  • Unintended consequences (e.g. availability of STI testing appointments, waiting time for diagnosis and/or treatment)
  • Awareness of STI testing and testing services
  • Changing STI diagnosis rate
  • The number of people at risk who intend to have an STI test
  • Condom use

Table 2Included effectiveness studies

StudyCountrySettingNPopulationInterventionComparatorFollow upOutcomes
Self-sampling kits
Klovstad (2013) NorwayRegional population41,519Young people aged 18–25Home test kit sent by mailUsual care available at clinicsWithin 3 monthsNumber of STI tests, STIs detected, treatment received
Reagan (2012) USAHomes and clinics200MenHome based STI screeningClinic based STI screening10–12 weeks

Intervention Acceptability, attitude towards STI testing,

STIs detected

Smith (2015) AustraliaHomes and clinics600Women, heterosexual men, MSMThe addition of a postal home collection kit to a SMS reminder to re-testSMS reminder to return to clinic1–4 months

Number of STI tests,

STIs detected

Van den Broek (2012) The NetherlandsRegional population421,820Young people aged 16–29Postal invitations to use an internet site to request a home test kitUsual care available at clinics6 months

Number of STI tests,

STIs detected

Wilson (2017, 2019)UKOnline2063AdultsSMS with link to e-STI testing site to request a home test kitSMS with link to clinic testing6 weeksIntervention Acceptability, STI Testing Behaviour, STIs detected, treatment received, engagement with the program, speed of test results
Xu (2011), 2 trials reported in single paperUSAHomes and clinics811 and 404WomenHome test kit mailed to participant’s homeA clinic appointment was scheduled for rescreening3 months

STI Testing Behaviour, rescreening within a 7-week window,

STIs detected

Interventions to increase motivation to test
Booth (2014) UKFurther education colleges253Young people living in deprived areasA brief intervention based on the theory of planned behaviour and self-identityUsual chlamydia testing promotionNo follow up

STI Testing Behaviour, number of tests taken, STI testing intention,

attitude towards STI testing

Fuller (2015) UKAmateur football clubs153Men in football clubsA poster and a standardised brief screening promotion talk given by
  1. The team captain
  2. A healthcare professional
Poster-only screening promotionUp to 4 weeks

Number of STI tests,

STIs detected

Lim (2012) AustraliaOnline and via SMS994Young people aged 16–29Regular sexual health promotion messages via email and SMSNo emails or SMS messages3 months, 6 months, and 12 months

Intervention Acceptability, STI Testing Behaviour, condom use, STI knowledge,

speaking to a health practitioner about STIs

Roth (2015) USACommunity court143female defendantsGain framed messages and loss framed messages to offer a rapid chlamydia testNeutral message to offer a rapid chlamydia testNo follow up

Attitude towards STI testing,

STI knowledge

Tailored interventions to increase STI testing
Bauermeister (2015) USAOnline104Young men who have sex with menTailored intervention using YMSMs psychosocial data to personalise website contentNon-tailored access to online provider directory page30 daysIntervention Acceptability, STI Testing Behaviour, changes in sexual behaviour, self efficacy towards STI testing
Kang (2012) AustraliaOnline704Young people aged 16–25Personalised emails from a clinician (sexual health nurse or doctor)Impersonal email sent from the project mailbox6 monthsSTI Testing Behaviour, changes in sexual behaviour, attitude towards STI testing, number of STI tests, condom use, STI knowledge
Lustria (2016) USAUniversity1065AdultsTailored persuasive website content based on responses to a STD risk assessmentGeneral information about STDs taken from the CDC websiteNo follow upIntervention Acceptability, STI Testing Behaviour, STI testing intention, attitude towards STI testing
Mevissen (2011) NetherlandsUniversities and higher vocational training colleges218Heterosexual young adultsPersonalised safe sex advice with a virtual consultantNo intervention3 monthsCondom use STI testing
Mortimer (2015) AustraliaUniversity747Young people aged 18–29Access to online personally controlled health management systemNo accessVaried (October 2013, regardless of recruitment date)STI Testing Behaviour, STI testing intention, attitude towards STI testing, speaking to a health practitioner about STIs
Financial incentives
Dolan (2014) UKOnline2988Young people aged 16–24Five types of incentives to return specimens: 1. reward vouchers of differing values, 2.charity donation, 3. participation in a lottery, 4. choices between a lottery and a voucher, and 5. including vouchers of differing values in the test kit prior to specimen return.No incentive provided, usual care30 daysNumber of STI tests, specimen return rate
Niza (2014) UKUniversity halls of residence1060Young people living in student hallsIncentive offered in the form of either a £5 voucher or a £200 lotteryNo incentive offeredNot providedNumber of STI tests
Computer assisted interview for increasing uptake of STI testing within sexual health clinics
Richens (2010) UKSexual health clinics2351Adults
  1. Computer-assisted self-interview (CASI), using a tablet (touchscreen) computer in private.
  2. Computer-assisted personal interview (CAPI), patient and clinician viewing the screen together
Pen and paper interview (PAPI) with a clinician following the normal clinic practice of completing a proforma with the patient (usual care)No follow up

STI Testing Behaviour, number of STI tests,

STIs detected, referral to health counsellors, identification of contraceptive needs, disclosure of sexual history

Table 3Remote self sampling compared to clinic tests for Increasing uptake of STI testing

Remote self sampling compared to clinic tests for Increasing uptake of STI testing

Patient or population: patients with Increasing uptake of STI testing

Settings: non-clinical settings

Intervention: Remote self sampling

Comparison: clinic tests

OutcomesAbsolute risk

Relative effect

(95% CI)

No of Participants

(studies)

Quality of the evidence

(GRADE)

Tests taken

number of participants who completed STI testing

 Study population

RR 1.93

(1.09 to 3.43)

362901

(6 studies1,2,3,4,5,6)

⊕⊝⊝⊝

very low7,8, 12

88 more per 1000 (from 9 more to 231 more)

Tests taken - Large population studies

number of participants who completed STI testing

 Study population

RR 2.46

(0.65 to 9.35)

358823

(2 studies1,4)

⊕⊝⊝⊝

very low7,9,10, 14

134 more per 1000 (from 32 fewer to 766 more)

Tests taken - Sample studies

number of participants who completed STI testing

 Study population

RR 1.76

(1.36 to 2.27)

4078

(4 studies2,3,5,6)

⊕⊝⊝⊝

very low 7 , 11

224 per 1000

395 per 1000

(305 to 509)

STIs detected

number of positive results

 Study population

RR 1.71

(1.13 to 2.57)

362901

(6 studies1,2,3,4,5,6)

⊕⊝⊝⊝

very low 7 , 8 , 12

5 per 1000

9 per 1000

(6 to 14)

Moderate
30 per 1000

51 per 1000

(34 to 77)

STIs detected - Large population studies

number of positive results

 Study population

RR 1.79

(0.85 to 3.79)

358823

(2 studies1,4)

⊕⊝⊝⊝

very low7,9,10, 14

5 per 1000

9 per 1000

(4 to 19)

Moderate
5 per 1000

9 per 1000

(4 to 19)

STIs detected - Sample studies

number of positive results

 Study population

RR 1.64

(1.04 to 2.6)

4078

(4 studies2,3,5,6)

⊕⊝⊝⊝

very low7, 11,12

24 per 1000

40 per 1000

(25 to 64)

Moderate
39 per 1000

64 per 1000

(41 to 101)

STIs diagnosed from tests taken

number of positive results

 Study population

RR 0.84

(0.6 to 1.18)

53648

(6 studies1,2,3,4,5,6)

⊕⊝⊝⊝

very low 7 , 8 , 12

57 per 1000

48 per 1000

(34 to 67)

Moderate
103 per 1000

87 per 1000

(62 to 122)

STIs diagnosed from tests taken - Large population studies

number of positive results

 Study population

RR 0.74

(0.41 to 1.34)

52306

(2 studies1,4)

⊕⊝⊝⊝

very low7,9,10, 12

54 per 1000

40 per 1000

(22 to 72)

Moderate
80 per 1000

59 per 1000

(33 to 107)

STIs diagnosed from tests taken - Sample studies

number of positive results

 Study population

RR 0.94

(0.64 to 1.38)

1342

(4 studies2,3,5,6)

⊕⊝⊝⊝

very low11, 13, 14

109 per 1000

103 per 1000

(70 to 151)

Moderate
103 per 1000

97 per 1000

(66 to 142)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.

Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Very low quality: We are very uncertain about the estimate.

1
2
3
4
5
6
7

Downgraded twice because of significant heterogeneity (I2 > 75%)

8

Downgraded twice for 2 indirectly applicable studies and 3 partially appliable studies

9

Downgraded twice for 1 study with high risk of bias and 1 study with some concerns

10

Downgraded twice for 1 indirectly applicable study and 1 partially appliable study

11

Downgraded once for 2 partially applicable studies and 1 indirectly applicable study

12

Downgraded once for crossing one MID/lone of no effect

13

Downgraded once for inconsistency i2 > 50%

14

Downgraded twice for crossing two MIDs

Table 4Motivation for Increasing uptake of STI testing compared to standard promotion

Motivation for Increasing uptake of STI testing compared to standard promotion

Patient or population: patients with Increasing uptake of STI testing

Setting: non-clinical settings

Intervention: Motivation

Comparison: standard promotion

OutcomesIllustrative comparative risks* (95% CI)

Relative effect

(95% CI)

No of Participants

(studies)

Quality of the evidence

(GRADE)

Assumed risk

Control

Corresponding risk

Motivation

Tests

number of participants who completed STI testing

 Study population

RR 1.06

(0.89 to 1.26)

756

(3 studies1,2,3)

⊕⊝⊝⊝

very low 4 , 5

266 per 1000

282 per 1000

(237 to 336)

Moderate
615 per 1000

652 per 1000

(547 to 775)

Tests - Cluster trials

number of participants who completed STI testing

 Study population

RR 0.95

(0.71 to 1.28)

154

(1 study1)

⊕⊝⊝⊝

very low6, 10

615 per 1000

585 per 1000

(437 to 788)

Moderate
615 per 1000

584 per 1000

(437 to 787)

Tests - RCTs

number of participants who completed STI testing

 Study population

RR 1.14

(0.91 to 1.42)

602

(2 studies2,3)

⊕⊝⊝⊝

very low 5 , 7

203 per 1000

231 per 1000

(185 to 288)

Moderate
636 per 1000

725 per 1000

(579 to 903)

Intention to get tested

7 point scale. Scale from: 1 to 7.

The mean intention to get tested in the control groups was

0

The mean intention to get tested in the intervention groups was 0.42 higher (0.84 lower to 0 higher)

253

(1 study8)

⊕⊕⊕⊝

moderate 9

Attitude towards testing

7 point scale. Scale from: 1 to 7.

The mean attitude towards testing in the intervention groups was 0.42 higher (0.72 to 0.12 higher)

253

(1 study8)

⊕⊕⊕⊝

moderate 9

Condom use

number of ‘always’ responses Follow-up: 6 months

 Study population

RR 0.71

(0.44 to 1.16)

(1 study2)

⊕⊝⊝⊝

very low 5 , 6

124 per 1000

0 per 1000

(0 to 0)

Moderate

Contact with a sexual health clinician

Follow-up: 6 months

 Study population

RR 1.16

(0.83 to 1.62)

(1 study2)

⊕⊝⊝⊝

very low 5 , 6

211 per 1000

0 per 1000

(0 to 0)

Moderate
*

The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.

Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Very low quality: We are very uncertain about the estimate.

1
2
3
4

Downgraded twice for 2 studies with high risk of bias

5

Downgraded once for crossing one MID/line of no effect

6

Downgraded twice because all studies are high risk of bias

7

Downgraded once for one study with high risk of bias

8
9

Downgraded once because study indirectly applicable

10

Downgraded twice for crossing both MIDs

Table 5Tailored interventions compared to non-tailored intervention for increasing uptake of STI testing

Tailored interventions compared to non-tailored intervention for increasing uptake of STI testing

Patient or population: patients with Increasing uptake of STI testing

Settings: non-clinical settings

Intervention: Tailoring

Comparison: non-tailored interventions

OutcomesIllustrative comparative risks* (95% CI)

Relative effect

(95% CI)

No of Participants

(studies)

Quality of the evidence

(GRADE)

Comments

Assumed risk

Control

Corresponding risk

Tailoring

Tests

number of participants who completed STI testing

 Study population

RR 1.38

(1.16 to 1.63)

1882

(4 studies1,2,3,4)

⊕⊝⊝⊝

very low 5 , 6 , 7

195 per 1000

268 per 1000

(226 to 317)

Moderate
190 per 1000

262 per 1000

(220 to 310)

Intention to get tested mean survey responses Follow-up: 0–3 months

The mean intention to get tested in the intervention groups was

0.34 higher

(0.2 to 0.48 higher)

1177

(2 studies2,8)

⊕⊕⊝⊝

low 9 , 10

Intention to get tested

number who answered yes

Follow-up: 2–6 months

 Study population Not estimable

375

(1 study1)

⊕⊕⊕⊝

moderate 11

124 per 1000

0 per 1000

(0 to 0)

Moderate

Attitude towards testing

number who answered that testing is relevant Follow-up: 2–6 months

 Study population Not estimable

375

(1 study1)

⊕⊕⊕⊝

moderate 11

182 per 1000

0 per 1000

(0 to 0)

Moderate

Attitude towards testing

mean survey responses. Scale from: 1 to 5.

The mean attitude towards testing in the intervention groups was

0.4 higher

(0.23 to 0.31 higher)

112

(1 study8)

⊕⊕⊕⊝

moderate 11

Condom use

mean survey responses. Scale from: 0 to 2.

Follow-up: 3 months

The mean condom use in the intervention groups was

0.26 higher

(0.04 to 0.56 higher)

78

(1 study8)

⊕⊕⊕⊝

moderate 11

Contact with sexual health clinician

number who answered yes

Follow-up: 2–6 months

 Study population

RR 1.6

(1.1 to 2.4)

375

(1 study1)

⊕⊕⊝⊝

low 11 , 12

187 per 1000

299 per 1000

(205 to 448)

Moderate
*

The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.

Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Very low quality: We are very uncertain about the estimate.

1
2
3
4
5

Downgraded once for 3 studies with some concerns and 1 study with high risk of bias

6

Downgraded once for 1 partially applicable study and 1 indirectly applicable study

7

Downgraded once for confidence intervals that cross the line of no effect

8

Mevission 2014

9

Downgraded once because both studies have some concerns for risk of bias

10

Downgraded once for large confidence intervals that cross the line of no effect

11

Downgraded once for some concerns about risk of bias

12

Downgraded once for large confidence intervals

Table 6Computer assisted interview clinic interventions compared to standard pen and paper interviews for increase in uptake of STI testing

Clinic interventions for Increasing uptake of STI testing

Patient or population: patients with Increasing uptake of STI testing

Settings: clinical

Intervention: Computer assisted interview interventions

Comparison: Standard pen and paper interview

OutcomesIllustrative comparative risks* (95% CI)

Relative effect

(95% CI)

No of Participants

(studies)

Quality of the evidence

(GRADE)

Comments
Assumed riskCorresponding risk
ControlClinic interventions

Number of tests completed

number of participants who completed STI testing

 Study population

RR 0.99

(0.97 to 1.01)

2319

(1 study1)

⊕⊕⊝⊝

low 2 , 3

946 per 1000

937 per 1000

(918 to 956)

Moderate
946 per 1000

937 per 1000

(918 to 955)

Positive results

number of participants with positive STI results

 Study population

RR 1.05

(0.82 to 1.36)

2319

(1 study)

⊕⊝⊝⊝

very low 2 , 4

100 per 1000

105 per 1000

(82 to 136)

Moderate
100 per 1000

105 per 1000

(82 to 136)

*

The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.

Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Very low quality: We are very uncertain about the estimate.

1
2

Downgraded once for risk of bias for all studies having some concerns

3

Downgraded once for confidence intervals crossing the line of no effect

4

Downgraded twice, once for large confidence intervals and once for confidence intervals crossing the line of no effect

Table 8

StudyLimitationsApplicabilityOther commentsIncrementalUncertainty
CostsEffectsCost-effectiveness

Bracebridge (2012)

Cost-effectiveness evaluation of a chlamydia trachomatis screening service using global dispatch of testing kits, web-based data collection and test reporting, and treatment dispatch by post.

Minor limitationsaApplicable

Study description

Evaluation of a cross-sectional study by NEEPCT;1 year time horizon; no discounting; NHS perspective; comparator was NCSP.

Probabilistic results

Cost of screening and partner notification for NEEPCT with set up costs (£): 268,198

Cost of screening and partner notification for NEEPCT without set up costs (£): 238,686

Cost of screening and partner notification for NCSP (£): 46,300,000

Probabilistic results

Number screened and diagnosed (%):

NEEPCT: 152 (4.4)

NCSP: 72,570 (7.4)

Number of partners notified:

NEEPCT: 26

NCSP: 29028

Partner notification efficacy:

NEEPCT: 0.17

NSCP: 0.4

Test positivity (combined partner and screen):

NEEPCT: 4.4

NCSP: 9

Probabilistic results

The cost per positive diagnosis was higher for the NEEPCT programme (£1,746) compared to the existing NSCP (£506). The cost per screening test and per positive diagnosis are 1.66 and 3.5 times higher for the NEEPCT than the NCSP average, respectively, making NEEPCT not cost-effective when compared with NCSP

Analyses was limited to data on sex, age and Index of Multiple Deprivation (IMD) for the predictors of test uptake.

Reviewer identified:

They used simplistic costing that does not consider factors such as the cost savings from preventing STI transmission.

Jackson (2015)

Preliminary cost-consequence analysis to compare the cost and outcomes of captain-led, sexual health advisor-led and poster STI screening promotion among men in football clubs in England.

Minor limitationsaPartly applicable

Study description

Preliminary cost-consequence analysis; NHS perspective.

Probabilistic results

Total cost of intervention (£):

Captain-led: 2491.61

Health advisor-led: 2738.09

Poster-only: 2538.09

Average cost of player screened (£):

Captain-led: 88.99

Health advisor-led: 88.33

Poster-only: 81.87

Probabilistic results

Number of players tested:

Captain-led: 28

Health advisor-led: 31

Poster-only: 31

Percent of players accepting screening offer:

Captain-led: 50

Health advisor-led: 67

Poster-only: 61

Probabilistic results

The results suggested that the total costs and average cost per player tested were similar across all interventions. No intervention was judged to be dominant.

Screening uptake could not be estimated for any single intervention arm so conclusions about the relative cost-effectiveness of interventions could not be drawn.

Uptake of STI testing may have been underestimated as the analysis did not capture additional downstream testing that may have occurred as a result of the intervention.

Review identified

As the analysis was a preliminary economic analysis, full incremental results were not calculated and only limited sensitivity analyses were conducted.

Kerry-Barnard (2020)

Cost analysis alongside the Test n Treat feasibility trial of screening for chlamydia trachomatis (CT) and neisseria gonorrhoeae (NG)

Minor limitationsaPartly applicable

Study description

Cost analysis; one-year time horizon; NHS perspective

Probabilistic results

Cost per student (£):

1a.

Average uptake non-incentivised: 237

1b.

Lowest uptake non-incentivised: 1082

1c.

Highest uptake non-incentivised: 88

1d.

Half the average uptake non-incentivised: 448

1e.

Double the average uptake non-incentivised: 13

2.

Average incentivised uptake: 91

3.

Maximum incentivised uptake: 47

Probabilistic results

Number of students screened, per day, per college:

1a.

5

1b.

1

1c.

17

1d.

2.5

1e.

10

2.

19

3.

49

Probabilistic results

Results showed that higher uptake of the Test n Treat service reduced the cost per screen. The study results suggest that incentivising testing could help increase uptake without reducing positivity rates.

Although most test times were documented, some were estimates.

The study may not be widely applicable as it was focused on six colleges in South London, where there is access to multiple NHS sexual health services. Costs may be higher in other settings and uptake of services may be higher in other settings.

Only a small number of students was screened per day which meant that the per student cost was sensitive to changes in the number of students screened per day.

Review identified

The study did not consider any outcomes and so did not calculate any incremental results.

No sensitivity analyses were conducted.

Looker (2019)

Economic evaluation of six different recall methods for the retesting of chlamydia positive individuals.

Minor limitationsaApplicableEconomic evaluation; one-year time horizon; no discounting; NHS perspective.Intervention cost per person (£; 10–14 weeks since treatment of first infection):
  1. Client-led: 55.54
  2. Reminder card: 55.64
  3. SMS invitation: 58.28
  4. Phone invitation: 67.31
  5. Automatic postal test kit: 44.83
  6. Advice at follow-up and SMS: 70.05
Chlamydia Retest rate (%):
  1. Client-led; 5%
  2. Reminder card; 4%
  3. SMS invitation; 8%
  4. Phone invitation; 6%
  5. Automatic postal test kit; 10%
  6. Advice at follow-up and SMS; 12%
Adjusted cost per retest (£; incorporating incomplete uptake/non-return of kits):
  1. Client-led: 109
  2. Reminder card: £130
  3. SMS invitation: 120
  4. Phone invitation: 289
  5. Automatic postal test kit: 190
  6. Advice at follow-up and SMS: 195

They did not specifically look at the effect of factors such as gender, country of birth, sexual orientation, perceived risk of infection and presence of symptoms on retest uptake and therefore cost

They did not consider other important factors besides cost such as the demography of the population: for example, automatically sending out postal kits might be the only feasible option in rural areas.

Abbreviations: IMD: Index of Multiple Deprivation; NCSP: National Chlamydia Screening Programme; NEEPCT: North East Essex Primary Care Trust; NHS: National Health Service;

Abbreviations: NHS: National Health Service; NIHR: National Institute for Health Research; PSA: probabilistic sensitivity analysis; RCT: randomised controlled trial; STI: sexually transmitted infection; UK: United Kingdom

Abbreviations: CT: chlamydia trachomatis; NG: neisseria gonorrhoeae; NHS: National Health Service; NIHR: National Institute for Health Research; PSA: probabilistic sensitivity analysis; UK: United Kingdom

Abbreviations: NCSP: National Chlamydia Screening Programme; SMS: Short Message Service; QALY: quality-adjusted life year

a

Minor limitations included: the study did not consider cost savings from preventing STI transmission and no sensitivity analysis was conducted.

a

Minor limitations include: uptake of STI testing may have been underestimated, full incremental results were not calculated and only limited sensitivity analyses were conducted.

a

Minor limitations include: the study was not widely applicable to other settings, only a small number of students were screened per day, the study did not calculate incremental results and no sensitivity analyses were conducted.

a

Minor limitations include: the study did not consider the effect of specific factors on retest uptake and cost.

Table 9Summary of partially extracted studies included in the economic evidence review for STI testing uptake (RQ2.1)

deWit (2015): The Netherlands
PopulationInterventionsEvaluation detailsEffectiveness resultsCost resultsICERComments
16–29-year-olds from three Dutch regionsRepeated register-based screening of Chlamydia. Six different scenarios were modelled
  1. Invite all 16- 29-year-olds annually
  2. Invite all women aged 16–29 years for annual screening
  3. Invite 16– 24 years for annual screening
  4. Only sending invitations every two years.
  5. Sending invitations every two years to women only
  6. Screening every five years

Evaluation type:

Cost-effectiveness analysis

Perspective

Societal perspective

Time horizon

10 years

Discounting

Costs discounted at 4% and effects were discounted at 1.5%

QALYs:
  1. Annual screening: 135
  2. Women only: 112
  3. 16–24-year olds: 105
  4. Biennial: 107
  5. Biennial women: 73
  6. Every five years: 77
Total cost per infection treated (€):
  1. Annual screening: 6144
  2. Women only: 4998
  3. 16–24-year olds: 5535
  4. Biennial: 5041
  5. Biennial women: 5066
  6. Every five years: 2739

Of all the scenarios screening every five years was the most cost-effective.

Cost per QALY gained (€):

  1. Annual screening: 232,143
  2. Women only: Dominated by its next best alternative
  3. 16–24-year olds: Dominated by its next best alternative
  4. Biennial: 156,000
  5. Biennial women: Dominated by its next best alternative
  6. Every five years: 61,214

Register-based Chlamydia screening in the Netherlands was found to have relatively unfavourable cost-effectiveness ratios.

Unfavourable cost-effectiveness was related to low uptake rates of the screening offer and further declining participation in consecutive rounds of screening.

Sensitivity analyses showed that even the lowest utility values (for the decrements associated with infections) would not have changed the conclusion on the cost-effectiveness of screening.

Gillespie (2012): Ireland
Individuals aged 18–29 years old who accessed one of three healthcare settings-general practices, family planning or student health clinicsOpportunistic screening of Chlamydia trachomatis

Evaluation type:

Prospective cost analysis

Perspective

Health provider perspective

Time horizon

10 years

Discounting

3.5%

Major outcomes (MO): pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility in women, neonatal conjunctivitis and pneumonia, and epididymitis in men.

MO:

Screening programme:

618

No screening:

1317

Cost (€):

Screening programme:

4,960,942

No screening:

720,074

The screening programme gave an ICER of €94,717 per QALY gained

The screening programme is unlikely to be considered cost effective by policy makers in Ireland.

Programmes which target at-risk individuals may be more likely to be considered cost-effective.

The analysis was taken from the health provider perspective meaning other resource implications such as costs incurred by wider society were not considered.

UK resource utilisation, unit costs and utility data were used as national data was not readily available.

Ritchie (2014): New Zealand
Outpatients from the Auckland City Hospital adult HIV clinicOpt-out screening of chlamydia, gonorrhoea and syphilis

Evaluation type:

Economic evaluation

Perspective

Health care provider perspective

Time horizon

9 months

Discounting

None

STIs were not detected in women or heterosexual men. Treatable STIs were diagnosed in 10% of MSM

MSM who screened positive for chlamydia:

27 cases (2%)

MSM who screened positive for gonorrhoea:

4 cases (<1%)

MSM who screened positive for syphilis:

5 cases (1%)

Total cost per case diagnosed (NZ$):

MSM Urine sample:

5309

MSM Rectal

swab sample:

664

MSM Throat swab sample:

3265

MSM Serum sample:

837

Not applicable

The study used simplistic costing that does not consider factors such as the cost savings from preventing STI transmission.

This service was not fully integrated into their existing clinic visits. Therefore having test results available by the time the patient attends their next scheduled clinic visit will greatly reduce the resources required.

Ross (2016): Canada
All users of four web platforms (Grindr, Facebook, Squirt and the Gay Ad Network)Campaign to highlight syphilis outbreak and importance of seeking testing: advertisements on four web platforms (Grindr, Facebook, Squirt and the Gay Ad Network)

Evaluation type:

Cost and effectiveness evaluation

Perspective

Not reported

Time horizon

Not reported

Discounting

3%

No difference in syphilis testing was observed in the post-campaign period

Mean cost per click (€):

Facebook:

68.18

Gay Ad Network:

60

Squirt:

2.47

Grindr:

1.09

Not applicable

Both the Squirt and Grindr ads were cost-effective, compared to the Facebook and Gay Ad Network ads, but no relation was found between the campaign and testing rates

Many assumptions were made in the analysis of the intervention, some of which may have been incorrect. For example, the target audience may have been too broad. It was unknown which proportion of men seeking testing were MSM; this subgroup may have been more likely to seek increased testing
Smith (2016): Australia
Participants from REACT trial (200 women, 200 heterosexual men, 200 MSM)SMS reminders and home-based retesting and versus clinic-based testing of STIs

Evaluation type:

Economic evaluation alongside an RCT

Perspective

Societal perspective

Time horizon

Lifetime

Discounting

3% and 5%

Not applicable

Overall cost per person (AUD $):

Home retest pathway:

154

Clinic-based retest pathway:

169

Cost per repeat infection detected (AUD $):

Home retest:

1,409

Clinic-based retest:

3,133

Not applicable

The study did not estimate indirect costs, such as the cost to the patient. For example, the inclusion of transport costs in the clinic pathway would have increased the cost of this intervention

Participants were not blinded to the study arm which may have impacted on their likelihood to retest

Tuite (2014): Canada
The model simulated 500,000 individual men similar to those enrolled in the Ontario HIV Treatment Network Cohort StudyaFrequent screening and screening with higher population coverage compared with usual care

Evaluation type:

Economic evaluation using an individual-level state-transition simulation model

Perspective

Public health payer perspective

Time horizon

Lifetime

Discounting

5%

Mean QALY per person:

Higher coverage

6 months:

13.3497

3 months:

13.3548

Annual:

13.3468

Usual care:

13.3398

Mean cost per person (CDN $):

Higher coverage

6 months:

1019.51

3 months:

1408.94

Annual:

1059.74

Usual care:

1310.25

Incremental cost ($)

Higher coverage three-month screening vs. usual care: 98.69

Incremental QALYs

Higher coverage three-month screening vs. usual care: 0.015

ICER (Cost CND $/QALY):

Higher coverage three-month screening vs. usual care: 77,516.35

The ICER was cost-saving when with higher coverage strategies (screening frequency of 3 or 6 months)

Although the model made large assumptions and included parameters with uncertainty, the sensitivity analyses showed that the findings were still robust

The analysis was restricted to HIV-positive MSM and did not consider MSM with no previous STIs

Additional evidence on benefit of higher coverage of screening in a population with no previous STIs would be useful

Abbreviations: ICER: incremental cost-effectiveness ratio; MOA: major outcome averted; QALY: quality-adjusted life year

Abbreviations: ICER: incremental cost-effectiveness ratio; MO: major outcome; QALY: quality-adjusted life year; UK: United Kingdom

Abbreviations: HIV: human immunodeficiency viruses; ICER: incremental cost-effectiveness ratio; MSM: men who have sex with men; NZ: New Zealand; STI; sexually transmitted infection

Abbreviations: ICER: incremental cost-effectiveness ratio; MSM: men who have sex with men

Abbreviations: AUD: Australian dollar; ICER: incremental cost-effectiveness ratio; MSM: men who have sex with men; RCT: randomised controlled trial; REACT: retest after Chlamydia trachomatis; STI: sexually transmitted infection

Abbreviations: CDN: Canadian dollar; HIV: human immunodeficiency viruses; ICER: incremental cost-effectiveness ratio; MSM: men who have sex with men; QALY: quality-adjusted life year; STI: sexually transmitted infection

a.

Burchell AN, Allen VG, Moravan V, Gardner S, Raboud J, et al (2013) Patterns of syphilis testing in a large cohort of HIV patients in Ontario, Canada, 2000–2009. BMC Infect Dis 13: 246. [PMC free article: PMC3668135] [PubMed: 23710699]

Table 2.1PICOS

Eligibility criteriaContent
Population

Sexually active people from age 16.

This will include younger people who contact or use sexual health services and are considered to be Gillick competent and satisfies the Fraser guidelines.

Factors

Factors that influence the acceptability of the strategies for improving testing uptake in individuals who are the target of these strategies.

(This will include interventions or strategies identified in RQ2.1, but is not restricted to these)

ComparatorNot applicable
OutcomesOutcomes will include individual perspectives, experiences, values, beliefs, preferences, views and considerations that influence the acceptability of the strategies.
Study typeQualitative studies

Table 2.2Summary of studies included in the qualitative review

StudyDesign and analysisSettingSample sizePopulationObjective
Aicken, 2016 In depth interviewsFurther Education college2516–24 year old college studentsTo explore perceptions and acceptability of remote STI self-testing and associated online care pathways to treatment (a hypothetical intervention), among young people from an Inner-London locality with high rates of STIs and large populations of Black Caribbean and African ethnic origin
Estcourt, 2016 Semi structured interviews with popular opinion leader theoryAmateur football clubs32 in total18–35 year old men who play in an amateur football club.
  • To develop, through qualitative research and consumer and stakeholder consultation, two feasible and replicable interventions for delivering STI screening in football club venues.
  • To determine the acceptability to young men and the feasibility of football trainer-led STI and HIV screening.1
Fleming, 2020 Semi structured interviews with Goffman’s theory of stigma and the construct of ‘candidacy’Technical FE colleges where “Test n Treat” intervention was offered26 in total: 13 who attended testing and 13 who did not.16–24 year old college studentsTo evaluate the trial implementation, to offer explanatory theories as to the success or failure, and to inform future research and/or service provision decisions:
  • Is the provision of rapid chlamydia and gonorrhoea testing in technical colleges viewed as acceptable and appropriate by students?
  • What are the barriers and facilitators to uptake as perceived by young people, teaching staff and on-site researchers?
  • What factors or strategies might improve uptake of rapid chlamydia and gonorrhoea testing in technical colleges from the perspectives of young people, teaching staff and on-site researchers?
Fuller, 2019 Semi structured interviewsSexual health clinics61Heterosexual and MSM STI clinic service usersThere is less knowledge of patient perspectives on how implementation of these technologies may change patient care, and no published research on patient perspectives for implementing AMR POCTs in SHCs. [Inferred aim to provide this]1
Gkatzidou, 2015 Focus GroupsHigher education and further education institutions.4916–24 year old studentsTo identify users’ functional and non-functional user interface design requirements and propose design recommendations applicable to mobile sexual health application user interface design.
Hogan, 2010 Semi structured interviews with Theory of Planned BehaviourGP surgeries3616–24 year olds attending general practice
  • Determine young people’s opinion of being offered a chlamydia screen at their GP surgery and to determine whether these differ in GP surgeries with high and low screening rates.
  • Identify what provisions are needed within GP surgeries to optimise the quality and effectiveness of delivery of the NCSP
Jackson 2021 Interviews and focus groupsCommunity centres and sexual health clinics41Young people age 16 – 24
  • Identify the characteristics of STI screening provision that are important to young people;
  • Establish young people’s preferences for different characteristics of STI screening and how these vary by subgroup;
  • Understand how young people make trade-offs between different service characteristics.
Jones, 2017 Semi structured interviews with Theory of Planned BehaviourGP surgeries3016–24 year olds attending general practiceTo expand on the previous research and use qualitative methods to explore patients’ attitudes to this wider 3Cs and HIV offer, using the theory of planned behaviour to provide an understanding of any potential facilitators or barriers to implementing this intervention.1
Loaring, 2013 Focus GroupsBrook centre (sexual health for under-25s)12Young people attending the clinicTo report the experiences, meanings and reality of participant’s feelings towards chlamydia screening
Lorimer, 2013 Focus GroupsUniversity and community spaces6016–24 year old menTo explore the barriers and facilitators to implementing an Internet-based chlamydia screening approach, including the acceptability of such an approach.
Middleton 2021 Interviews and focus groupsCommunity spaces2516–65 MSM and heterosexual men and women with mild learning disabilityTo explore barriers and facilitators to correct use of an STI/BBV self-sampling pack among people with mild learning disabilities.
Normansell, 2016 Semi structured interviews (single or in pairs) with ‘Candidacy’, the theory of planned behaviour, and stigma theoriesFurther education college1716–27 year old female studentsTo explore access and attitudes to STI screening in high risk, 20 young, ethnically diverse female students recruited outside of the healthcare system.
Powell, 2016 Semi structured interviews with Protection Motivation Theory and Theory of Planned BehaviourUniversity18University students who had used a self-test kitTo explore self-testing for chlamydia from the perspective of young adults, to identify factors that may predict self-testing outside the context of formal screening programmes and to understand how self-test use impacts on individuals. A key secondary aim was to identify theoretical domains that explain the qualitative findings and which could form an effective framework for further research.
Richardson, 2010 Unstructured interviewsFE colleges and University1416–24 year olds students who declined a chlamydia testTo develop themes and hypotheses from interviewing young people declining chlamydia testing as to why they declined the test.
Wayal, 2011 Semi structured interviewsSexual health clinic24Men who have sex with men, who have used a self-test kit.To evaluate the feasibility and acceptability of home sampling kits for STI/HIV and to evaluate the sensitivity and specificity of self-collected rectal and oropharyngeal specimens to detect Chlamydia trachomatis and Neisseria gonorrhoea among men who have sex with men. In this paper we explored participants’ views to inform the development of services offering home sampling kits for STI/HIV1
1

Data regarding HIV testing, condom distribution, and sexual health services other than testing were not extracted

Table 2.3Summary of themes and sub-themes

Major themeSub-themes
Reasons for testingMost participants accepted testing for peace of mind.
Few participants tested because of their sexual health risk status.
Many participants reported testing in order to receive an incentive.
Accessibility of self-sampling to people with mild learning disabilitiesParticipants with mild learning disabilities lacked confidence with testing and wanted support.
Participants with mild learning disabilities had difficulty understanding the test instructions
Participants with mild learning disabilities found it difficult to use the test kit.
Intervention quality and practicalitiesParticipants were concerned about data security.
Several participants questioned the accuracy of tests used outside of clinic settings.
Participants had some concerns about the practicalities and reliability of using phone apps and the postal service.
Design and credibility of the interventionVisibility, familiarity and advertising increased trust in the service.
Aesthetics, language, and design appeal influenced how participants felt about the intervention.
Participants wanted to access testing using technology that fulfilled their needs and matched their preferences.
The experience of using the testConvenience was frequently mentioned as one of the main benefits of these interventions.
Speed was an important aspect for many participants.
Many participants described self-test kits as easy to use.
Some participants felt anxiety about sexual health screening, both with and without the interventions.
Some participants expressed a desire for more control and choice in their screening experiences.
Confidentiality and stigmaParticipants highly valued a confidential and anonymous service.
The ability to conceal testing from others was important.
Many participants were concerned about embarrassment.
Participants were concerned that people may make inferences about their sexual behaviour.
Gender performativity1 can increase or decrease stigma.
Involvement of healthcare professionalsFace to face interaction can positively or negatively influence how comfortable participants feel about testing.
Participants valued personal support from a healthcare provider.
Some participants felt they needed a healthcare profession’s involvement for practical assistance and clarification.
Where the tests are availableSome participants preferred to receive sexual health services within a medical setting.
Participants appreciated being offered testing in social community spaces.
Self tests were reviewed positively by most who used them.
Some participants preferred sexual health clinics and felt that testing in other settings was not appropriate.
1

Gender performativity is the act of behaving in ways that adhere to and reinforce the social constructs of masculinity and femininity

Table 2.4Summary of the qualitative evidence

FindingStudiesIllustrative quotesCERQual explanationConfidence
Reasons for testing
Most participants accepted testing for peace of mind. They did so opportunistically, when they would not have sought out a sexual health clinic

Estcourt 2016b

Powell 2016

Wayal 2011

“I didn’t have any reason to be concerned about having Chlamydia, I just wanted it to be for peace of mind”

“as they offered I didn’t see the point in turning it down”

Downgraded twice for minor concerns about adequacyModerate

Few participants tested because of their sexual health risk status. Many had little knowledge of STIs and no awareness of their own risk and so were not driven to test by their perception of their risk status.

Despite this, there were mixed opinions on providing education alongside the interventions. Some took the opportunity to ask questions, but others found it off-putting.

Estcourt 2016a

Estcourt 2016b

Fleming 2020

Fuller2019

Hogan 2010

Jackson 2021

Jones 2017

Loaring 2013

Normansell 2015

Wayal 2011

“‘I mean, even I don’t really know what chlamydia is and I’m 24, so a lot of young people don’t know.’”

“Do you think I’m going to sit here, like really? Am I going to read this? I don’t even read my course work.”

Downgraded twice for moderate concerns about coherenceLow
Many participants reported testing in order to receive an incentive. However, this acted as a facilitator to getting tested, but rather than it being because they wanted the reward, it was because participants felt they could avoid stigma by claiming they were taking part to gain the incentive rather than admitting to wanting to be tested.

Powell 2016

Loaring 2013

Fleming 2020

“If you were to give out condoms more boys would come”Downgraded once for minor concerns about relevance and adequacyModerate
Accessibility of self-sampling to people with mild learning disabilities (MLDs)
Participants with mild learning disabilities lacked confidence with testing and wanted support. Most participants with MLDs had little existing knowledge or understanding of STI testing. Participants felt anxious and overwhelmed by trying to follow the test kit’s instructions and did not feel confident approaching the task. Many said that they would want support to use the kit, and most of these participants preferred to get help from a GP or support worker. Middleton 2021 “I‘d rather go to the doctor’s, ‘cause then you’d know what’s getting done, right then”Downgraded twice, for moderate concerns about adequacy and minor concerns about coherenceLow

Participants with mild learning disabilities had difficulty understanding the test instructions. They found the written instructions too long and difficult to read. The diagrams were helpful for some, but others struggled to interpret the anatomic sites they showed.

They suggested ways that this could be improved, in particular they felt that YouTube videos demonstrating the kits would be easier to follow.

 Middleton 2021 “See, you wouldn’t know if that’s the back to the front… [on anatomical diagram]”Downgraded twice, for moderate concerns about adequacyLow
Participants with mild learning disabilities found it difficult to use the test kit. Some participants had problems with motor skills and manual dexterity, which made it difficult to take blood samples. Some women did not have enough knowledge of their genitalia to complete the test. Participants were also concerned that the tests would not be effective if they did not complete them correctly. Middleton 2021 “you could have taken it incorrectly, and it would have given an improper reading”Downgraded twice, for moderate concerns about adequacyLow
Intervention quality and practicalities
Participants were concerned about data security. This made them cautious about disclosing personal information without knowing why it is needed and how it will be used.

Aicken 2016

Fleming 2020

Gkatzidou1 2015

“I am quite careful about where I put my data online, as soon as one of these companies gets a piece of information, it just goes to everybody”

“Why are you asking for postcode? …Full postcode narrows it down to a street, so if you are in the middle of nowhere and there are no families living around there, within the range they could trace it back to you.”

Downgraded once for minor concerns about relevanceModerate

Several participants questioned the accuracy of tests used outside of clinic settings. More specifically, some were concerned that the tests were able to be distributed widely because they were cheaper and therefore possibly poorer quality.

Some participants also expressed distrust of ‘faceless’ healthcare and were concerned about the expertise of the people involved in the testing program.

Wayal 2011

Powell 2016

Jones 2017

Gkatzidou1 2015

Estcourt 2016a

Aicken 2016

“How do I know that this medication that they are prescribing me is the right one… and WHO is this person prescribing me?”

“[a cheap test] might not be as accurate”

No downgrading requiredHigh

Participants had some concerns about the practicalities of the proposed interventions. They felt that rapid testing would not be as fast in reality if there is high demand to use the service.

Those using home tests were concerned that the software might be unreliable or that their samples could be damaged or lost in the post.

Wayal 2011

Powell 2016

Fuller2019

Aicken 2016

“if the clinic has one [machine], and you see people every five minutes, you’re going to end up with a massive queue just to wait half-an hour for each test”

“No, I’ve got the most useless postman in the world. I get other people’s mail and it horrifies me to think what mail other people might get of mine.”

Downgraded once for minor concerns about relevanceModerate
Design and credibility of the intervention

Visibility, familiarity and advertising increased trust in the service. Participants felt were more willing to use a well-known and established testing program.

Association with the NHS was frequently mentioned as an indicator of credibility.

Wayal 2011

Loaring 2013

Jones 2017

Hogan 2010

Gkatzidou1 2015

Estcourt 2016b

Estcourt 2016a

Aicken 2016

“That it’s part of the NHS? It makes me feel safe, it makes me feel okay,”

“‘I mean this is totally new, so you would think twice before trusting it. If I saw it advertised somewhere, or available in Boots then I would think it is …you know…legit’”

Downgraded once for minor concerns about relevanceModerate
Aesthetics, language, and design appeal influenced how participants felt about the intervention. Young people wanted language that appealed to them but were critical of attempts to appear ‘cool’ which they found patronising. They considered a professional looking design to be more appropriate and give the impression of taking their health seriously as an adult issue.

Lorimer 2013

Gkatzidou1 2015

Estcourt 2016b

“Why do they keep putting, like, “R U” and stuff? I actually don’t know anyone who texts like that anymore.”

“See, the first one [website], I would not type my details.”

“It’s a graffiti font there. I can’t take that seriously… It’s not about being bad websites, but serving a purpose. In this case, it’s about health, it’s not about being cool, which that website aims”

No downgrading requiredHigh
Participants wanted to access testing using technology that fulfilled their needs and matched their preferences. Some wanted specific features such as reminders and others were particular about which platforms were best suited to delivering the intervention. Many were not willing to download a phone app for a single purpose. People with mild learning disabilities described feeling overwhelmed to varying degrees when opening the pack and did not know where to start.

Fleming 2020

Gkatzidou1 2015

Lorimer 2013

Middleton 2021

Normansell 2015

“I prefer web apps…I don’t like to download apps as it clogs up my phone, so having a web app means you can go to it without having downloaded it… I am not sure how many times I would use this app, so it would just get deleted…”

“So if there was a sort of set-up with advertising and with reminders and things, that would be really helpful because I have a memory like a leaky sieve.”

No downgrading requiredHigh
The experience of using the test
Convenience was frequently mentioned as one of the main benefits of these interventions. Using self-test kits and making tests available in different settings enabled participants to access testing with minimal effort; they commented that they may not have scheduled a clinic visit but were happy to take a quick test in their own time.

Wayal 2011

Powell 2016

Normansell 2015

Lorimer 2013

Jones 2017

Jackson 2021

Hogan 2010

Fuller2019

Estcourt 2016b

Estcourt 2016a

Aicken 2016

“…you could be in the bath, be like using the toilet, and be like, let me just get this real quick and do this real quick. It’s… convenient, very convenient. That’s why I like it”

““I think cos its quite convenient as well cos I think if you’re working and everything it is a bit of a hassle trying to, it’s a hassle for me just to try and get to see my doctor; you have to kind of phone in advance and you have to phone in at a certain time and it’s a bit annoying. And then you have to have you’ve got the waiting as well. So I think it’s just, it’s more convenient and you can do it whenever really””

No downgrading requiredHigh

Speed was an important aspect for many participants. Most preferred a faster test with faster results. Some, however, were concerned that there would be a balance between speed and accuracy, in which case they would prefer a more accurate test to a fast one.

For participants who were asked about rapid point-of-care tests, the speed felt paradoxical: They were pleased to have their results faster, within an hour rather than a few days, however this meant a longer clinic visit was needed to allow time for that 30 minute wait. Some did find this acceptable as long as they were informed in advance and given a choice.

Aicken 2016

Estcourt 2016b

Fuller2019

Jackson 2021

Loaring 2013

Normansell 2015

Wayal 2011

““I think for any test you feel apprehensive and you feel uncomfortable. So any shortening of that time from test to solution is a positive thing in my eyes.”

“everything is fast now”

“Probably [I would prefer] less time [in clinic] and a text message in a few days”

Downgraded once for minor concerns about relevance and minor concerns about coherenceModerate
Many participants described self-test kits as easy to use. They felt confident that they had administered the test correctly and that the procedure for returning samples was simple and straightforward.

Aicken 2016

Estcourt 2016a

Estcourt 2016b

Jones 2017

Loaring 2013

Powell 2016

Wayal 2011

“. . it just seemed really easy”

“if it had a jiffy bag in to send them off and then post them I think would be the easiest… If they’re in the envelope you can just shove them in the letterbox and it’s done.”

No downgrading requiredHigh
Some participants felt anxiety about sexual health screening, both with and without the interventions. Some anxiety was about the experience of testing, but most focused on worries about receiving the results and how they would react to a positive test. This worry was sufficient for some participants to avoid seeking testing. Several participants stated that they would avoid testing until symptoms worsened.

Estcourt 2016a

Estcourt 2016b

Hogan 2010

Jackson 2021

Loaring 2013

Normansell 2015

Powell 2016

“They try to make you feel at ease but for me it just didn’t work. I wanted to cancel at the last min and then when I got there I felt like turning round and walking out.”

“Some people don’t like to know their results.. .they’d rather die.. .so it’s something like that, just scared of knowing what you’ve got”

“…probably just say ‘oh it’s just a bit of pain, nothing to worry about’”

No downgrading requiredHigh

Some participants expressed a desire for more control and choice in their screening experiences. There was anxiety about the invasive nature of some clinic tests and both the social and physical discomfort of being examined. These participants found self-test kits more acceptable as they allowed them to avoid this experience.

Some participants also wanted a choice in the type of self test, as they would feel more comfortable giving a urine sample instead of a swab. Some participants did not feel like they were able to refuse or ask for different test options.

Estcourt 2016a

Fuller2019

Jackson 2021

Jones 2017

Powell 2016

Richardson 2010

“..if they have to get their kit off in front of someone else it’s quite embarrassing.. . let’s face it putting your legs up in those stirrups is not the most dignified position in the world!”

““you can choose as well the method … but you feel like less pressured and more relaxed and you can take your time… it’s like, it’s all your own decision””

“because it really wasn’t what I expected, um, I just expected to do a urine test and it wasn’t and it gave you sort of an instruction list of how to do the swab em, but yeah it was a bit scary”

No downgrading requiredHigh
Confidentiality and stigma
Participants highly valued a confidential and anonymous service. This was often described as a crucial element of any intervention or test service. Home test kits were particularly praised for allowing participants to test with no face-to-face interaction.

Aicken 2016

Estcourt 2016a

Estcourt 2016b

Fleming 2020

Jackson 2021

Jones 2017

Lorimer 2013

Powell 2016

Wayal 2011

“I saw that there was just a drop box, sort of no one, yeah, I thought it was good because it was confidential.”

“The anonymous part of this is just brilliant compared to having to sit [at a clinic]”

“would rather that ‘cause there’s not no one in front of me like talking to me or looking at me…”

No downgrading requiredHigh
The ability to conceal testing from others was important. Participants did not want to be seen taking or returning test kits or to have their results returned in a format that others could access. Several participants stated that their phones and post were not private.

Aicken 2016

Estcourt 2016a

Fleming 2020

Gkatzidou1 2015

Hogan 2010

Jackson 2021

Jones 2017

Loaring 2013

Powell 2016

Richardson 2010

“I live in halls and you know how it is, people just constantly grab your phone off you to check what games and apps you got… I have a passcode on my phone, but that is like 4 digits, my mates already know it anyway’.”

“you’ve got to walk past the really busy reception with your … with your wee sample or something, but I mean that’s a problem in a lot of places”

No downgrading requiredHigh

Many participants were concerned about embarrassment. The stigma of STIs most commonly manifested as humiliating or shameful to be associated with, so even asymptomatic testing required courage to be seen doing.

Young people were particularly worried about their parents finding out they took a test, as many had not told their parents about their sexual activity.

Aicken 2016

Estcourt 2016a

Estcourt 2016b

Fleming 2020

Gkatzidou1 2015

Hogan 2010

Jackson 2021

Jones 2017

Loaring 2013

Lorimer 2013

Normansell 2015

Powell 2016

Richardson 2010

“‘I grew up in a Christian family…and this is a ‘hot topic’…. I wouldn’t want my sister, or my mum or my dad finding an app on my phone that says sexual.”

“I’d find it quite embarrassing going to a clinic and just like you know, everyone knowing you had unprotected sex or whatever. But erm, yes so I think the idea of doing it at home is like, is quite a good thing”

“It depends on the age range and the maturity range I think because now at 20 I don’t give a damn and I think my parents would be quite happy that I’m getting screened. But 18 year old me did not want my parents knowing about any of it.. . sex and parents just don’t go together, they don’t”

No downgrading requiredHigh

Participants were concerned that people may make inferences about their sexual behaviour. They feared being judged as ‘unclean’ or ‘slutty’. Some participants applied these views to others who use sexual health services.

Participants also said that they would react negatively if their partner accepted a test and believed their partner would do likewise.

Aicken 2016

Estcourt 2016a

Fleming 2020

Hogan 2010

Jones 2017

Lorimer 2013

Normansell 2015

Powell 2016

Richardson 2010

Wayal 2011

“..well going to the clinic.. .all the people there.. ..it’s full of skanky 15 year olds”

“..it seems like you sleep around or…that you’re not careful…I think there’s a lot of stigma attached to it; it’s thought of as dirty I suppose and just a bit slutty if you have one [STI] ”

“It might change the way I thought about them slightly … there’s nothing very sexy about a sexually transmitted disease”

Downgraded once for minor concerns about coherenceModerate

Gender performativity can increase or decrease stigma. Some young men used humour to enforce norms of rejecting testing. Adult men counteracted stigma by encouraging a ‘lads together’ approach to normalise testing while emphasising masculinity.

MSM felt a particular need for privacy due to homophobia.

Estcourt 2016a

Estcourt 2016b

Fleming 2020

Loaring 2013

Wayal 2011

“cos it’s in a lads’ environment, it’s all like, oh he’s got a testing kit, he must be getting some action. That kind of thing. So I think ‘cos it’s in that environment I don’t really think people would be embarrassed about it. They’ll probably go, yeah, you know, I had this girl last week and a girl the week before and you just get a bit, a lot of egos flying about and it will create a lot of banter I think.”

“large groups of boys, you know ‘showboating’ around, making negative comments and jokes about sexual diseases”

No downgrading requiredHigh
Involvement of healthcare professionals
Face to face interaction influences how comfortable participants feel about testing. Some participants felt judged and uncomfortable seeking testing from clinic staff so preferred to avoid interaction. Others were encouraged to test by interacting with providers who had a rapport and familiarity with them.

Estcourt 2016a

Hogan 2010

Jones 2017

Middleton 2021

Normansell 2015

“It was horrible, they were so judgemental…like they would say if you’re pregnant and you lie about your address and that like they’ll get social services involved and they’ll tell your mum.”

“Because if you’ve got a doctor that’s coming in it’s immediately, ‘Oh he’s a doctor. How am I going to relate to a doctor?’ If he’s a 50-year-old doctor you’re not. If he’s someone closer to their age then you are much more likely to”

Downgraded twice, for moderate concerns about coherence and minor concerns about relevanceLow
Participants valued personal support from a healthcare provider. This was particularly important when receiving test results. They felt they would not know what to do about a positive result on their own and would want to have it explained to them so they could ask questions and seek reassurance.

Aicken 2016

Estcourt 2016b

Hogan 2010

Jones 2017

Powell 2016

Wayal 2011

“I’d be a little scared because that’s the thing, I need my doctor to just tell me, calm me down and tell me like, you know, it’s not the end of the world we can fix it. But if I’m at home by myself, you know. I think I would just go a little crazy because I wouldn’t know what to do with it”

“if it’s something on your phone you don’t really wanna read so much. But if you can talk to someone, not a computer, someone real, then you’re most likely to listen”

No downgrading requiredHigh
Some participants felt they needed a healthcare professional’s involvement for practical assistance and clarification. Participants who used a self-test kit that involved a questionnaire sometimes did not understand the questions or could not give a straightforward answer to them. Some participants also did not feel confident administering the test themselves. Participants with mild learning disabilities voiced a need for someone else to help navigate the pack. For some, the complexity of the pack and the knowledge and understanding required to undertake self-sampling meant that they would rather go to their general practitioner (GP) or sexual health service than try themselves.

Estcourt 2016b

Gkatzidou1 2015

Hogan 2010

Jones 2017

Middleton 2021

Powell 2016

Wayal 2011

“I am worried that people might have something completely unrelated, like ‘rash’; some people have eczema, so they might be worried. So it is assuming that it means a rash….well…’down there’…but maybe it actually should specify”

“I would have probably asked them to do it in all honesty; I probably would have asked them, yeah… I didn’t necessarily have the confidence in myself”

“I‘d rather go to the doctor’s, ‘cause then you’d know what’s getting done, right then.”

Downgraded once for minor concerns about coherenceModerate
Where the tests are available

Some participants preferred to receive sexual health services within a medical setting. They felt GP surgeries were the appropriate place to be offered a health intervention and they had an established trusting relationship with the staff.

Medical expertise was seen as the key advantage accessing tests here rather than community settings.

Aicken 2016

Hogan 2010

Jones 2017

Loaring 2013

Middleton 2021

Wayal 2011

“If I was concerned about chlamydia, I’d rather do it at my GP’s surgery because my GP knows me and I’d feel more sort of comfortable discussing options with them, and knowing that they know my history and stuff like that”

“I’m much more easily prepared to talk about things [to] … people who you think are qualified medically I suppose, do you know what I mean? Rather than a shop assistant”

Downgraded once for minor concerns about relevance and coherenceModerate

Participants appreciated being offered testing in social community spaces. It was seen as more convenient to take the opportunity as it was offered than to seek out testing.

The presence of friends often acted as a facilitator to testing in social spaces, as testing together as a group removed the embarrassment of making an individual decision to test. Young women in particular often encouraged each other to take a test.

Estcourt 2016a

Estcourt 2016b

Fleming 2020

Gkatzidou1 2015

Hogan 2010

Loaring 2013

Powell 2016

Wayal 2011

“I’d probably, being a boy, I’d prefer it how I have just done it with the football team… I suppose if you’re doing it like how your team done it, then I suppose it makes people feel a bit more relaxed and stuff. It certainly made me a bit more relaxed than going to the doctor’s or something.”

“One of my mates said you might as well do it. I was like, OK, I might as well see as well. So that’s why I did it”

““I was doing my Florence Nightingale bit and saying how I’d done some research.””

Downgraded once for minor concerns about coherenceModerate
Self-tests were well reviewed by most who used them. There was a lot of general enthusiasm about the option to complete a test at home. Participants felt that the privacy and control over the situation removed a lot of the barriers they associated with other test locations.

Aicken 2016

Fleming 2020

Jones 2017

Loaring 2013

Lorimer 2013

Normansell 2015

Wayal 2011

“If I had to do it, if I was going to be, see myself round and I needed to get tested, I would choose this option [Internet screening] over going to the GP or the clinic.”

“Just get it done quicker, just get it out there fast. Cos it sounds good, so it should be out there”

Downgraded once for minor concerns about relevanceModerate

Some participants preferred sexual health clinics and felt that testing in other settings was not appropriate. In some social spaces, sexual health interventions can feel ‘preachy’ or serve as an unwelcome reminder of poor health. In GP surgeries, some participants felt patronised by being profiled for a test when they wanted to use their appointment time to discuss a different medical issue.

Some felt that where to test depended on the context for wanting a test. They were happy to use the intervention services for asymptomatic routine testing but would want the full clinic experience if they had symptoms or believed themselves to be at risk.

Estcourt 2016b

Fleming 2020

Fuller2019

Jones 2017

Lorimer 2013

Normansell 2015

Powell 2016

Wayal 2011

“Doing a urine sample there and then is, ummm, is just extra GP time and maybe that would take away from time you need to actually talk about the problem that you came in for”

“on the gay scene, .. . because people were always sticking buckets in my face or doing things, handing out safe sex packs and things and sometimes my friend when he … the guy who died, when he went into a club he didn’t want to remember [being HIV positive], he just wanted to go out there and socialise and have a good time …”

“I think if I had symptoms I would go straight to a clinic because it’s obviously something that needs … you know medical [intervention]”

No downgrading requiredHigh

Final

Evidence reviews underpinning recommendations 1.2.1 to 1.2.9 and research recommendations in the NICE guideline

National Institute for Health and Care Excellence

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2022.
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