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A Pilot of Mail-Out HIV and Sexually Transmitted Infection Testing in Washington, District of Columbia During the COVID-19 Pandemic

      Introduction

      In 2019, the District of Columbia recorded a 20-year low rate in new HIV infections but also had near-record numbers of gonorrhea and chlamydia infections. District of Columbia Department of Health has supported numerous forms of community-based in-person screening but not direct at-home testing.

      Methods

      In summer 2020, the District of Columbia Department of Health launched GetCheckedDC.org for District of Columbia residents to order home-based oral HIV antibody test and urogenital, pharyngeal, and rectal chlamydia and gonorrhea tests. Initial and follow-up surveys were completed by individuals for both test modalities.

      Results

      A retrospective analysis was conducted for the first 5 months of the program. During that period, 1,089 HIV and 1,262 gonorrhea and chlamydia tests (535 urogenital, 520 pharyngeal, 207 rectal) were ordered by 1,245 District of Columbia residents. The average age was 33.1 (median=31, range=14−78) years; 51.6% of requestors identified as Black; 39.3% identified as men who have sex with men; 16.2% reported no form of insurance; and 8.1% and 10.4% reported never being testing for HIV and sexually transmitted infections, respectively. More than half of people requesting tests reported convenience and COVID-19 as the reasons. In total, 39.5% of sexually transmitted infection tests were returned; 7.22% of people testing for sexually transmitted infections received a positive result, and 10.35% of rectal tests were positive. No individuals reported a positive HIV self-test that was confirmed; 98.5% of respondents said that they would recommend the HIV self-test kit.

      Conclusions

      Mail-out HIV and sexually transmitted infection testing was readily taken up among high-priority demographics within a diverse, urban, high-morbidity jurisdiction during the COVID-19 pandemic. Extragenital testing for gonorrhea and chlamydia should be included in all at-home screening tests given the high positivity rate.

      INTRODUCTION

      In the District of Columbia (DC) and nationwide, HIV and sexually transmitted infections (STIs) continue to greatly impact public health and well-being. In 2019, the District documented 282 new HIV, 9,337 Chlamydia trachomatis, and 4,374 Neisseria gonorrhoeae cases.
      DC.gov., DC Health
      HAHSTA annual epidemiology & surveillance report 2020.
      Although this marks a 59% decrease in new HIV cases since 2012, the incidence of new chlamydia and gonorrhea diagnoses over this period increased by 32% and 79%, respectively.
      DC.gov., DC Health
      HAHSTA annual epidemiology & surveillance report 2020.
      The link between undiagnosed STIs and increased HIV transmission risk underscores the importance of expanded access to STI screening as a core component to end the HIV epidemic, although expanded use of pre-exposure prophylaxis (PrEP) adds complexity to this relationship.
      • Hayes R
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      Over the last 2 decades, HIV and STI testing outside the clinical environment has increased access to and has facilitated engagement in care. This can occur either through rapid self-testing—where an individual collects a specimen, runs the test, and receives and interprets the results—or by a mail-in self-test—where an individual collects a specimen outside of a healthcare setting and then sends the specimen to a laboratory for analysis. Rapid HIV self-testing kits were first approved in the U.S. in 2012. Although initial adoption was limited, 31 states or jurisdictions were providing free HIV self-tests programs as of January 2021.
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      • Powers KA
      Self-testing for HIV and its impact on public health.
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      Free HIV self-test programs. Greater than AIDS. https://www.greaterthan.org/at-home-test-kit-programs/. Updated May 12, 2021. Accessed January 19, 2021.

      Studies show that rapid HIV self-testing can increase testing among people with risk behaviors who otherwise rarely test by increasing ease of use, convenience, and availability. However, they also have drawbacks such as lower sensitivity, inconsistent post-test counseling, and potential challenges with linkage to care.
      • Johnson CC
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      • et al.
      Examining the effects of HIV self-testing compared to standard HIV testing services: a systematic review and meta-analysis.
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      Mail-in self-testing for chlamydia and gonorrhea has been available since the early 2000s.
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      Mail-in self-testing programs for STIs have noted high uptake, high patient satisfaction, and test positivity rates similar to those of in-person clinical testing.
      • Gaydos CA
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      Internet-based screening for Chlamydia trachomatis to reach non-clinic populations with mailed self-administered vaginal swabs [published correction appears in Sex Transm Dis. 2007;34(8):625].
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      • et al.
      Use of home-obtained vaginal swabs to facilitate rescreening for Chlamydia trachomatis infections: two randomized controlled trials.
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      Studies have found variable positivity and return rates between 30% and 70%.
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      Mail-in self-testing programs, when partnered with community clinics and local health departments, note high treatment rates.
      • Gaydos CA
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      • Barnes M
      • et al.
      Internet-based screening for Chlamydia trachomatis to reach non-clinic populations with mailed self-administered vaginal swabs [published correction appears in Sex Transm Dis. 2007;34(8):625].
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      Can e-technology through the Internet be used as a new tool to address the Chlamydia trachomatis epidemic by home sampling and vaginal swabs?.
      The novel coronavirus disease 2019 (COVID-19) pandemic has profoundly influenced testing but has had equivocal impacts on sexual behavior. Social distancing measures began to be implemented in the U.S. starting in March 2020. Early data suggest declines in direct clinical services and sexual health screenings as well as observed decreases in HIV and STI diagnoses in DC.
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      DC Government. HIV/AIDS, Hepatitis, STD and TB Administration
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      Surveys of men who have sex with men (MSM) from early in the pandemic are conflicting with other studies seeing little to no change in casual sexual behavior and in the number of casual sex partners or little or no willingness to decrease the number of sexual partners but possible decreases in condom-less anal sex, and another study showing more than half of those surveyed reported decreased numbers of sexual partners.
      • Sanchez TH
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      Evaluating the impact of COVID-19: a cohort comparison study of drug use and risky sexual behavior among sexual minority men in the U.S.A.
      Data from early in the pandemic suggest that despite decreased testing, PrEP use has remained high with a shift to telemedicine or virtual patient encounters.
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      With limitations on HIV and STI screening services and continued sexual activity throughout the pandemic, there is a pressing need for alternative testing options. Although the DC Department of Health (DC Health) has supported clinician-based, hospital, emergency department, and community-based in-person HIV screening, it did not distribute rapid HIV self-test options before the COVID-19 pandemic. Stay-at-home orders, social distancing policies, and new federal guidance led DC Health to develop and pilot GetCheckedDC to expand testing options to residents unable to leave their place of residence and who may experience barriers to conventional testing opportunities and locations.
      In this paper, the authors provide an interim analysis of the first 5 months of GetCheckedDC to evaluate the usage and public health impact of free, delivered rapid HIV self-tests and mail-in STI self-testing in an economically and racially diverse city. The authors compare demographic, geographic, and morbidity-associated factors with each testing modality to investigate the characteristics of those requesting tests. The authors assess the positivity rates and the characteristics of those who return chlamydia and gonorrhea tests. The authors hypothesize that by reducing the accessibility barriers for testing, they will see both a high demand of test requests and a high rate of return among groups disproportionately affected by HIV, gonorrhea, and chlamydia in DC.

      METHODS

      Study Population

      On June 27, 2020, DC Health launched GetCheckedDC.org. Initially, the website allowed District residents to order rapid HIV self-testing kits through a secure online request form. Individuals received a package to their stated address within Washington, DC that included an OraQuick In-Home HIV self-test kit, prevention materials, and documentation of local resources. The costs for rapid HIV self-tests during the pilot period were $21 dollars per kit, whereas shipping and packaging costs were $8 dollars per order. Participants received a secure post-test survey automatically delivered by e-mail 2 weeks after their order to optionally self-report their result. Test results were obtained only through the post-test survey and associated clinical follow-up, and positive results could only be calculated if disclosed in the follow-up survey.
      On September 7, 2020, the program expanded to include chlamydia and gonorrhea screening through mail-in self-testing. DC residents could request urogenital, pharyngeal, and rectal chlamydia and gonorrhea nucleic acid amplification tests. All-inclusive costs were $25.20 per test and $8.50 per specimen collection material ordered by the participant. Specimen collection kits were directly mailed from a remote laboratory, which included self-collection and sample preparation instructions. After laboratory receipt and processing of specimens, results were provided to patients through a secure online patient portal and by direct encrypted e-mail. Notification of positive results and linkage to treatment was conducted by DC Health Disease Intervention Specialists.
      Participants answered a pretest survey on initial request for testing services through the website. The pretest survey asks the following of each participant: test kit selection (HIV/STI), demographic information (age, gender, ethnicity, race, healthcare access), sexual partner information in the last 12 months (gender, number, condom use frequency, methods of meeting), testing and PrEP information (time since the last HIV/STI test, any previous STI or HIV diagnoses, awareness of PrEP, availability of PrEP, reason[s] for requesting at-home testing), and contact information (name, mailing address, e-mail, phone).
      GetCheckedDC participants also received an automated e-mail delivered 14 days after the initial order, encouraging completion of a post-test survey. Literature encouraging completion of the post-test survey was also included inside the package with the test kit(s). If the post-survey was not completed, an automatic reminder e-mail was generated in 14 days, which was repeated in an additional 14 days if not completed. In total, participants were reminded 5 times (4 electronic, 1 physical) to complete the post-test survey. The post-test survey asked each participant the following: which test kits were used (HIV/STI), when the kit was delivered, when the participant used the test, the reason for not having used the test (if applicable), the result of HIV test (positive, negative, can't tell), (if the preliminary HIV test was positive) Have you contacted a provider yet for follow-up testing, when will you get tested again, do you recommend the at-home test kit(s)? and space for any qualitative feedback about the process or program. The question about HIV test result was contingent on reporting the use of the test. The question regarding the time of kit delivery was added after July 15, 2020 after 13 people had already completed the survey.
      The program was announced and promoted through mayoral announcements and advertising. Short advertisements were featured on local radio and TV stations, print media (both lesbian, gay, bisexual, transgender, and queer focused and for general audiences), and displayed on buses and bus shelters. Social media marketing comprised most advertising on sites and applications, including Facebook, Instagram, Hornet, Jack'd, and Grindr. Social media marketing (Facebook, Instagram, YouTube) was $17,000 or 17% of the total cost, dating applications marketing (Hornet, Grindr, Jack'd, Facebook) was $14,000 or 13%, and traditional media (bus advertising, lesbian, gay, bisexual, transgender, and queer print/digital publication, radio, TV) was $71,500 or 70% of the total marketing cost. Program promotion continues on multiple social media platforms. From September 8 through the end of the study period, of the 7,908 unique users of the GetChecked website, 1,597 clicked through to the survey and order form to provide a conversion rate of 0.202.

      Measures

      Respondents were included in the analysis if they completed a request between the launch of the program on June 27 and December 7, 2020. Mail-in STI self-test results were limited to only those reported before December 21, 2020. Only orders with mailing addresses within DC were included. Requests were cross-matched with shipping lists to remove duplicate requests.

      Statistical Analysis

      Summary statistics were developed using aggregated respondent responses. Statistical analysis was conducted using Stata, version 11. Univariable tests for significance were conducted with continuous variables being analyzed using t-tests and categorical variables using Pearson chi-square and Fisher's exact tests as appropriate for the sample size included in the comparison. Reference groups were selected for specific groups of variables when appropriate, and rate ratios were calculated. The primary outcomes for the study were the number of tests ordered and the number of tests either returned (for mail-in STI self-tests) or reported used (for rapid HIV self-tests). The secondary outcomes were the reported and resulted test positivity rates. The project was determined to be exempt from human subjects review by the DC Public Health IRB.

      RESULTS

      During the study period, a total of 1,245 requests were completed by DC residents delivering 1,089 rapid HIV self-tests and 1,262 mail-in STI self-tests (Table 1) with 51.6% self-identified as Black and 36.06% identified as non-Latinx White. More than half (56.1%) of individuals requesting tests identified as a cisgender male, and 39.9% identified as cisgender female. Nearly half (47.6%) documented having employer-sponsored insurance. Medicaid (19.6%) and no insurance (16.2%) were the next most common insurance. More than a third of participants had not received HIV or STI testing within the last 12 months (34.5% and 35.9%, respectively), and 9.0% and 9.6% had never tested for HIV or STIs. Always using condoms with partners over the last 12 months was reported by 14.5% of respondents.
      Table 1Home Testing by HIV and STI Requests
      HIVSTIAll
      Characteristicsn or mean% or median (range)n or mean% or median (range)n or mean% or median (range)
      Total requests (person)1,0896661,245
       Urogenital tests535
       Pharyngeal tests520
       Rectal tests207
      Age, years33.731 (14−78)29.327 (16−58)33.131 (14−78)
      Gender
       Cis-male61656.631046.569856.1
       Cis-female42939.433149.749739.9
       Trans-male30.330.540.3
       Trans-female30.310.230.2
       Other383.5213.2433.5
      Race
      A total of 6 individuals selected multiple races for HIV testing and STI testing (total numbers add up to 1,095 and 672, respectively). A total of 2 individuals were unique and did not overlap. DC Health, District of Columbia Department of Health; GC/CT, gonorrhea/chlamydia; MSM, men who have sex with men; MSMW, men who have sex with men and women; MSW, men who have sex with women; PrEP, nonoccupational pre-exposure prophylaxis; STI, sexually transmitted infection; WSM, women who have sex with men; WSMW, women who have sex with men and women; WSW, women who have sex with women.
       Black59354.532548.864351.6
       Non-Hispanic White37134.126039.044936.1
       Hispanic White494.5395.9645.1
       Asian, Native Hawaiian, other Pacific Islander595.4375.6655.2
       American Indian/Alaska Native232.1111.7262.1
      Insurance
       Employer insurance48444.427341.059347.6
       Uninsured15614.39514.320216.2
       Medicare454.1253.8574.6
       Medicaid19918.312618.924419.6
       Family member11710.710115.217013.7
       DC Health link888.1466.91008.0
      Meeting partners
       Social situations35132.222533.841233.1
       Clubs/bars17616.211016.520816.7
       Social media21219.512018.024419.6
       Apps55050.532849.262950.5
       Cruising686.2355.3725.8
       School/neighborhood968.811417.112610.1
      Last HIV or STI test
       <1 month161.5152.3
       1–3 months11210.39614.4
       4–6 months21419.711617.4
       7–12 months26424.215923.9
       >12 months39536.326840.2
       Never888.16910.4
      Total partners in the last 12 months4.23 (0−100)4.03 (0−30)4.33 (0−100)
      Sexual partnering
       MSM43840.219529.348939.3
       MSMW232.191.4241.9
       MSW17115.711417.120216.2
       WSM39135.929644.445336.4
       WSW262.4182.7302.4
       WSMW302.8243.6332.6
      STI history
       Chlamydia20018.414521.724819.9
       Gonorrhea14513.38913.3617313.9
       HIV00.00101.50100.8
       Syphilis585.3314.65715.7
       No history of STI77070.745768.686469.4
      Why HIV or STI testing by mail
       Site difficult to reach16214.88512.8
       Past experience at nearby test site(s)393.5263.9
       Don't know where to go928.5527.8
       Test with partner12511.5
       On PrEP152.3
       Don't want people to know16415.110015.0
       Convenience64959.641762.6
       COVID-1962257.141662.5
      Mailing address ZIP and HIV or GC/CT morbidity
       Address in 3 highest morbidity ZIP35433.120531.0
       Address in 5 highest morbidity ZIP50547.231547.7
       Address in 10 highest morbidity ZIP84679.150876.9
      a A total of 6 individuals selected multiple races for HIV testing and STI testing (total numbers add up to 1,095 and 672, respectively). A total of 2 individuals were unique and did not overlap.DC Health, District of Columbia Department of Health; GC/CT, gonorrhea/chlamydia; MSM, men who have sex with men; MSMW, men who have sex with men and women; MSW, men who have sex with women; PrEP, nonoccupational pre-exposure prophylaxis; STI, sexually transmitted infection; WSM, women who have sex with men; WSMW, women who have sex with men and women; WSW, women who have sex with women.
      People identified 4.25 (median=3) partners within the last 12 months. Nearly two fifths (39.3%) of participants identified as MSM and 36.4% as women who have sex with men; 69.4% reported no history of STIs. For using the program, convenience and the COVID-19 pandemic were identified as the primary reasons by nearly two thirds of respondents.
      In total, 39.3% of requested gonorrhea and chlamydia tests were returned to the laboratory (Table 2). Urogenital tests were more often returned (48.0%) than pharyngeal tests (37.5%) or rectal tests (42.0%). A total of 19 of 263 people who returned tests had a positive result (7.2%). A total of 8 of 257 (3.1%) urogenital tests were positive, with 7 positive chlamydia and 1 positive gonorrhea result. A total of 9 of 87 (11.5%) rectal tests were positive (6 chlamydia and 4 gonorrhea, with 1 individual positive for both gonorrhea and chlamydia), and 7 of 195 pharyngeal tests were positive (3 chlamydia and 4 gonorrhea). Two individuals had concurrent extragenital and urogenital positive tests. Treatment was confirmed for all cases.
      Table 2Comparison Between Returned and Not Returned Mail-Out STI Tests
      ReturnedNot returnedTotal%Rate ratiop-Value
      Characteristicsnnn
      Total requests26340366639.5
       Urogenital25727853548.0ref
       Pharyngeal19532552037.50.781<0.001
       Rectal8712020742.00.8750.141
      Positivity
       Person positive
      One person was both CT and GC positive.
      197.22
        Person chlamydia (CT) positive134.94
        Person gonorrhea (GC) positive72.66
       Urogenital tests positive83.11
        CT test positive72.72
        GC test positive10.39
       Pharyngeal tests positive73.59
        CT test positive31.54
        GC test positive42.05
       Rectal tests positive
      One rectal test was both CT and GC positive. CT, Chlamydia trachomatis; DC Health, District of Columbia Department of Health; GC, Neisseria gonorrhoeae; MSM, men who have sex with men; MSMW, men who have sex with men and women; MSW, men who have sex with women; PrEP, nonoccupational pre-exposure prophylaxis; STI, sexually transmitted infection; WSM, women who have sex with men; WSMW, women who have sex with men and women; WSW, women who have sex with women.
      910.35
        CT test positive66.90
        GC test positive44.60
      Age, years, mean (95% CI)30.27 (29.2, 31.3)31.15 (30.2, 32.0)0.213
      Gender
       Cis-male12818231041.3ref
       Cis-female12420733737.40.9070.321
       Trans-male21366.71.6150.374
       Trans-female0110.000.588
       Other9122142.91.0380.888
      Race
       Non-Hispanic White13013026050.0ref
       Hispanic White18213946.20.9230.654
       Black9722832529.80.597<0.001
       Asian, native Hawaiian, other Pacific Islander18193748.60.9730.878
       American Indian/Alaska Native381127.30.5450.121
       Other10162638.50.7690.262
      Insurance
       Employer insurance13513827349.5ref
       Uninsured29669530.50.6170.001
       Medicare7182528.00.5660.040
       Medicaid369012628.60.578<0.001
       Family member376410136.60.7410.027
       DC Health link19274641.30.8350.306
      Meeting partners
       Social situations9313222541.31.0790.487
       Clubs/bars555511050.01.5320.014
       Social media477312039.20.9870.936
       Apps15317532846.61.3400.000
       Cruising13223537.10.9050.770
       School/neighborhood437111437.70.9250.671
      Last STI test
       Never25366141.0ref
       <1 month591435.70.8710.481
       1−3 months38488644.21.0780.699
       4−6 months476411142.31.0330.863
       7−12 months618614741.51.0130.945
       >12 months8716024735.20.8590.402
      Total partners, mean (95% CI)4.43 (3.875, 4.977)3.37 (3.325, 4.14)0.046
      Sexual partnering
       MSM8910619545.61.2870.037
       MSMW63966.73.0650.093
       MSW397511434.20.7970.205
       WSM11118529637.50.9190.348
       WSW8101844.41.2260.663
       WSWM7172429.20.6310.292
      STI history
       CT667914545.51.2800.093
       GC47428952.81.7150.006
       HIV191010.00.1700.055
       Syphilis14173145.21.2620.508
       No history of STI16529245736.10.8660.008
      Why choosing mail-in STI testing
       Site difficult to reach33528538.80.9720.893
       Past experiences at nearby test site(s)8182630.80.6810.353
       Don't know where to go23295244.21.2150.466
       On PrEP871553.31.7510.267
       Don't want people to know316910031.00.6880.060
       Convenience17124641741.01.0650.300
       COVID-1917324341641.61.0910.153
      Mailing address ZIP and CT/GC morbidity
       Address in 3 highest STI morbidity ZIP6613920532.20.7230.009
       Address in 5 highest STI morbidity ZIP10820731534.30.7950.007
       Address in 10 highest STI morbidity ZIP19231650837.80.9250.078
      Note: Boldface indicates statistical significance (p<0.05).
      a One person was both CT and GC positive.
      b One rectal test was both CT and GC positive.CT, Chlamydia trachomatis; DC Health, District of Columbia Department of Health; GC, Neisseria gonorrhoeae; MSM, men who have sex with men; MSMW, men who have sex with men and women; MSW, men who have sex with women; PrEP, nonoccupational pre-exposure prophylaxis; STI, sexually transmitted infection; WSM, women who have sex with men; WSMW, women who have sex with men and women; WSW, women who have sex with women.
      Comparing the demographics of those who returned tests with those of those who requested but did not return the tests, people identifying as Black were significantly less likely to return tests (rate ratio=0.60, p<0.001) than people identifying as non-Hispanic White. People with Medicare and Medicaid were significantly less likely to return tests (rate ratio=0.57, p=0.040 and rate ratio=0.58, p<0.001, respectively) than those with employer-sponsored insurance. Uninsured individuals were also significantly less likely to return tests (rate ratio=0.62, p=0.001) than people with employer-sponsored insurance. Those who returned tests had significantly more partners (mean 4.4 vs 3.4, p=0.046) and were more likely to identify as MSM (rate ratio=1.29, p=0.037) than other sexual partners. In addition, those who returned tests were less likely to have a residence within both the third and fifth highest morbidity ZIP codes for gonorrhea and chlamydia (rate ratio=0.72, p=0.009 and rate ratio=0.80, p=0.007).
      Post-test surveys were returned by 33.2% of the participants (Table 3). Most respondents (79.5% for rapid HIV self-tests and 93.2% for mail-in STI self-tests) indicated receiving their kits within 1 week of request. Most people who responded reported testing within 1 week. More than 70% of respondents indicated that they would repeat testing within 6 months, and >98% of respondents indicated that they would recommend the testing service to others. Nearly all returned post-test surveys reported negative HIV test results, with 3 respondents unable to determine their test results. One individual reported a positive test, which was determined to be negative on follow-up testing, leading to a positivity rate of 0.
      Table 3HIV and STI 2-Week Follow-Up Results
      HIVSTITotal
      Survey questionsn%n%n%
      When were test kit(s) delivered?
      When Were Test Kit(s) Delivered? was not added as a response option for the initial 13 HIV survey respondents
       3 business days8928.42933.011829.4
       Within a week16051.15360.221353.1
       Within 1−2weeks4313.744.54711.7
       >2 weeks216.722.3235.7
      How long until using test?
       Within a day19459.53438.622855.1
       Within a week8626.44450.013031.4
       Within a month329.81011.44210.1
       Not taken144.300.0143.4
      Results
      A total of 14 HIV self-test respondents reported not yet using the self-test kit, and thus the results question was unavailable as an option. STI, sexually transmitted infection.
       Negative30999.08192.1
       Positive00.078.0
       Can't tell31.0
      When planning to repeat test?
       <1 month82.611.192.2
       1−3 months11536.74247.715739.2
       4−6 months11035.11921.612932.2
       7−12 months3511.21112.54611.5
       >2 months144.555.7194.7
       I don't know288.91011.4389.5
       I won't get another test31.000.030.7
      Would you recommend this test kit?
       Yes32198.58697.740798.3
       No51.522.371.7
      a When Were Test Kit(s) Delivered? was not added as a response option for the initial 13 HIV survey respondents
      b A total of 14 HIV self-test respondents reported not yet using the self-test kit, and thus the results question was unavailable as an option.STI, sexually transmitted infection.

      DISCUSSION

      GetCheckedDC showed brisk uptake among residents during its initial phase, with >1,000 rapid HIV self-tests provided over 5 months and >1,200 gonorrhea and chlamydia mail-in self-tests completed in 3 months. Requests came from a broad demographic of residents, but most critically, several groups disproportionately affected by HIV and STIs were reached by the program. For rapid HIV self-tests, 40.2% of tests were sent to individuals identifying as MSM, which represents 1.2% (438 of 36,775) of the total MSM population in DC.
      • Grey JA
      • Bernstein KT
      • Sullivan PS
      • et al.
      Estimating the population sizes of men who have sex with men in U.S. states and counties using data from the American Community Survey.
      In addition, 24.0% of people requesting rapid HIV self-tests identified as Black women who have sex with men, which closely parallels HIV incidence in DC, where nearly 1 in 4 individuals diagnosed with HIV over the last 5 years are Black women.
      DC.gov., DC Health
      HAHSTA annual epidemiology & surveillance report 2020.
      Tests were also largely requested by residents in need of testing, with 44.4% of residents receiving rapid HIV self-tests and 50.6% of those receiving mail-in STI self-tests reporting never testing for those diseases (8.1% for HIV and 10.4% for STIs) or having tested >1 year ago (36.3% for HIV and 40.2% for STIs). Furthermore, 85.5% reported inconsistent condom usage, and 76.8% reported >1 partner within the last year, suggesting that participants are accurately assessing risk and utilizing the program per established guidelines.
      Some significant socioeconomic and demographic differences appear among those who return mail-in STI self-tests. Individuals with employer-sponsored insurance were significantly more likely to return mail-in STI self-tests than those using other forms of health insurance or lacking insurance. Individuals residing in the top 5 ZIP codes in DC with the highest chlamydia and gonorrhea morbidity rates also were significantly less likely to return tests. Furthermore, people identifying as Black also were significantly less likely to return tests; however, the authors were unable to control for other covariates in this analysis, which may suggest other complicating factors. These disparities suggest a need for more selective promotion among focused geographic and racial groups because the convenience of home-based screening does not completely bridge the gap in STI screening services. This also underlines the importance of continuing HIV and STI screening services in clinical settings such as federally qualified health centers and categorical STI clinics with established connections to socioeconomically diverse, high-risk populations.
      GetCheckedDC underscores the importance of including extragenital screening in-home‒based STI testing initiatives. Although chlamydia positivity levels were lower than the established positivity rates, gonorrhea rates were consistent with the established literature. The authors found that 71.4% (5 of 7) of positive pharyngeal tests and 88.9% (8 of 9) of rectal positive tests would have been missed if only urogenital screening were conducted. In addition, this initiative allowed the authors to fully evaluate the positivity rates among the study population, which is unique for DC, which only received positive test result reports and not the number of individuals tested as part of regular STI surveillance reports.

      Limitations

      This study has several limitations. Less than one third of individuals ordering HIV tests reported their results despite numerous communications. At this time, the authors are unable to determine the public health impact of HIV self-testing and whether this pilot resulted in diagnosing new HIV infections. Additional strategies, including incentives and exploring alternative means of communication, should be considered to increase the response rate for post-test surveys. In addition, data are dependent on self-identified mailing addresses, which may not reflect a true home address or site of residence. The authors have noted that test return may be artificially low because the program provides no fixed deadline for return of tests. Individuals intending to return tests but not having done so yet may have been excluded. In addition, although this program allowed insight into test positivity rates, these program data should be considered in the context of the demographics tested rather than in that of DC as a whole, and given the small sample size of positive tests, the authors cannot correlate sociodemographic characteristics with positivity rates at this time.

      CONCLUSIONS

      The initial phase of GetCheckedDC has shown high demand for cost-free HIV and STI testing outside the clinical environment during a pandemic among residents with high-risk behaviors in a diverse urban jurisdiction. Testing was overall appropriately requested and reflected accurate self-determination of individual risk. Still, removing cost and convenience barriers to access HIV and STI testing did not fully address testing needs, with significant geographic and racial disparities persisting. The program further underscores the importance of mail-in testing for extragenital as well as urogenital sites. Overall, HIV and STI testing outside the clinical environment can serve as a critical adjunct to in-person clinical services.

      ACKNOWLEDGMENTS

      This program would not be possible without the support of numerous contributors. The authors would like to thank Michael Kharfen, Jason Beverley, Rachel Harold, Rick Elion, Danielle Perry, Leigha Mills, Minerva Bernal, Taylor Forte, and Bryan Collins.
      The research presented in the paper does not reflect the official policy of the government of the District of Columbia.
      Funding for sexually transmitted infection tests provided in the study was provided through a Gilead FOCUS grant.
      George Fistonich: Investigation, Resources, Writing - Original Draft, Methodology; Kenya Troutman: Investigation, Resources, Writing - Original Draft; Adam Visconti: Conceptualization, Methodology, Formal Analysis, Data Curation, Supervision, Project Administration, Writing - Original Draft, Writing - Review and Editing, Funding Acquisition.
      No financial disclosures were reported by the authors of this paper.

      SUPPLEMENT NOTE

      This article is part of a supplement entitled The Evidence Base for Initial Intervention Strategies for Ending the HIV Epidemic in the U.S., which is sponsored by the U.S. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). The findings and conclusions in this article are those of the author(s) and do not necessarily represent the official position of CDC or HHS.

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