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.
1
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.
HAHSTA annual epidemiology & surveillance report 2020.
DC.gov., DC Health,
Washington, DCPublished August 20, 2020
https://dchealth.dc.gov/node/1492101
Date accessed: January 11, 2021
1
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.DC.gov., DC Health
HAHSTA annual epidemiology & surveillance report 2020.
HAHSTA annual epidemiology & surveillance report 2020.
DC.gov., DC Health,
Washington, DCPublished August 20, 2020
https://dchealth.dc.gov/node/1492101
Date accessed: January 11, 2021
2
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.
3
,4
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.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.
5
, 6
, - Steehler K
- Siegler AJ
Bringing HIV self-testing to scale in the United States: a review of challenges, potential solutions, and future opportunities.
J Clin Microbiol. 2019; 57e00257–19https://doi.org/10.1128/JCM.00257-19
7
Mail-in self-testing for chlamydia and gonorrhea has been available since the early 2000s.
8
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.9
, 10
, 11
, 12
Studies have found variable positivity and return rates between 30% and 70%.13
Mail-in self-testing programs, when partnered with community clinics and local health departments, note high treatment rates.9
,14
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.
15
, 16
, 17
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.16
,18
,19
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.- Starks TJ
- Jones SS
- Sauermilch D
- et al.
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.
Drug Alcohol Depend. 2020; 216108260https://doi.org/10.1016/j.drugalcdep.2020.108260
20
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
| HIV | STI | All | ||||
|---|---|---|---|---|---|---|
| Characteristics | n or mean | % or median (range) | n or mean | % or median (range) | n or mean | % or median (range) |
| Total requests (person) | 1,089 | 666 | 1,245 | |||
| Urogenital tests | 535 | |||||
| Pharyngeal tests | 520 | |||||
| Rectal tests | 207 | |||||
| Age, years | 33.7 | 31 (14−78) | 29.3 | 27 (16−58) | 33.1 | 31 (14−78) |
| Gender | ||||||
| Cis-male | 616 | 56.6 | 310 | 46.5 | 698 | 56.1 |
| Cis-female | 429 | 39.4 | 331 | 49.7 | 497 | 39.9 |
| Trans-male | 3 | 0.3 | 3 | 0.5 | 4 | 0.3 |
| Trans-female | 3 | 0.3 | 1 | 0.2 | 3 | 0.2 |
| Other | 38 | 3.5 | 21 | 3.2 | 43 | 3.5 |
| Race 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. | ||||||
| Black | 593 | 54.5 | 325 | 48.8 | 643 | 51.6 |
| Non-Hispanic White | 371 | 34.1 | 260 | 39.0 | 449 | 36.1 |
| Hispanic White | 49 | 4.5 | 39 | 5.9 | 64 | 5.1 |
| Asian, Native Hawaiian, other Pacific Islander | 59 | 5.4 | 37 | 5.6 | 65 | 5.2 |
| American Indian/Alaska Native | 23 | 2.1 | 11 | 1.7 | 26 | 2.1 |
| Insurance | ||||||
| Employer insurance | 484 | 44.4 | 273 | 41.0 | 593 | 47.6 |
| Uninsured | 156 | 14.3 | 95 | 14.3 | 202 | 16.2 |
| Medicare | 45 | 4.1 | 25 | 3.8 | 57 | 4.6 |
| Medicaid | 199 | 18.3 | 126 | 18.9 | 244 | 19.6 |
| Family member | 117 | 10.7 | 101 | 15.2 | 170 | 13.7 |
| DC Health link | 88 | 8.1 | 46 | 6.9 | 100 | 8.0 |
| Meeting partners | ||||||
| Social situations | 351 | 32.2 | 225 | 33.8 | 412 | 33.1 |
| Clubs/bars | 176 | 16.2 | 110 | 16.5 | 208 | 16.7 |
| Social media | 212 | 19.5 | 120 | 18.0 | 244 | 19.6 |
| Apps | 550 | 50.5 | 328 | 49.2 | 629 | 50.5 |
| Cruising | 68 | 6.2 | 35 | 5.3 | 72 | 5.8 |
| School/neighborhood | 96 | 8.8 | 114 | 17.1 | 126 | 10.1 |
| Last HIV or STI test | ||||||
| <1 month | 16 | 1.5 | 15 | 2.3 | — | — |
| 1–3 months | 112 | 10.3 | 96 | 14.4 | — | — |
| 4–6 months | 214 | 19.7 | 116 | 17.4 | — | — |
| 7–12 months | 264 | 24.2 | 159 | 23.9 | — | — |
| >12 months | 395 | 36.3 | 268 | 40.2 | — | — |
| Never | 88 | 8.1 | 69 | 10.4 | — | — |
| Total partners in the last 12 months | 4.2 | 3 (0−100) | 4.0 | 3 (0−30) | 4.3 | 3 (0−100) |
| Sexual partnering | ||||||
| MSM | 438 | 40.2 | 195 | 29.3 | 489 | 39.3 |
| MSMW | 23 | 2.1 | 9 | 1.4 | 24 | 1.9 |
| MSW | 171 | 15.7 | 114 | 17.1 | 202 | 16.2 |
| WSM | 391 | 35.9 | 296 | 44.4 | 453 | 36.4 |
| WSW | 26 | 2.4 | 18 | 2.7 | 30 | 2.4 |
| WSMW | 30 | 2.8 | 24 | 3.6 | 33 | 2.6 |
| STI history | ||||||
| Chlamydia | 200 | 18.4 | 145 | 21.7 | 248 | 19.9 |
| Gonorrhea | 145 | 13.3 | 89 | 13.36 | 173 | 13.9 |
| HIV | 0 | 0.00 | 10 | 1.50 | 10 | 0.8 |
| Syphilis | 58 | 5.3 | 31 | 4.65 | 71 | 5.7 |
| No history of STI | 770 | 70.7 | 457 | 68.6 | 864 | 69.4 |
| Why HIV or STI testing by mail | ||||||
| Site difficult to reach | 162 | 14.8 | 85 | 12.8 | — | — |
| Past experience at nearby test site(s) | 39 | 3.5 | 26 | 3.9 | — | — |
| Don't know where to go | 92 | 8.5 | 52 | 7.8 | — | — |
| Test with partner | 125 | 11.5 | — | — | — | — |
| On PrEP | — | — | 15 | 2.3 | — | — |
| Don't want people to know | 164 | 15.1 | 100 | 15.0 | — | — |
| Convenience | 649 | 59.6 | 417 | 62.6 | — | — |
| COVID-19 | 622 | 57.1 | 416 | 62.5 | — | — |
| Mailing address ZIP and HIV or GC/CT morbidity | — | — | ||||
| Address in 3 highest morbidity ZIP | 354 | 33.1 | 205 | 31.0 | — | — |
| Address in 5 highest morbidity ZIP | 505 | 47.2 | 315 | 47.7 | — | — |
| Address in 10 highest morbidity ZIP | 846 | 79.1 | 508 | 76.9 | — | — |
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
| Returned | Not returned | Total | % | Rate ratio | p-Value | |
|---|---|---|---|---|---|---|
| Characteristics | n | n | n | |||
| Total requests | 263 | 403 | 666 | 39.5 | ||
| Urogenital | 257 | 278 | 535 | 48.0 | ref | |
| Pharyngeal | 195 | 325 | 520 | 37.5 | 0.781 | <0.001 |
| Rectal | 87 | 120 | 207 | 42.0 | 0.875 | 0.141 |
| Positivity | ||||||
| Person positive | 19 | 7.22 | ||||
| Person chlamydia (CT) positive | 13 | 4.94 | ||||
| Person gonorrhea (GC) positive | 7 | 2.66 | ||||
| Urogenital tests positive | 8 | 3.11 | ||||
| CT test positive | 7 | 2.72 | ||||
| GC test positive | 1 | 0.39 | ||||
| Pharyngeal tests positive | 7 | 3.59 | ||||
| CT test positive | 3 | 1.54 | ||||
| GC test positive | 4 | 2.05 | ||||
| Rectal tests 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. | 9 | 10.35 | ||||
| CT test positive | 6 | 6.90 | ||||
| GC test positive | 4 | 4.60 | ||||
| Age, years, mean (95% CI) | 30.27 (29.2, 31.3) | 31.15 (30.2, 32.0) | 0.213 | |||
| Gender | ||||||
| Cis-male | 128 | 182 | 310 | 41.3 | ref | — |
| Cis-female | 124 | 207 | 337 | 37.4 | 0.907 | 0.321 |
| Trans-male | 2 | 1 | 3 | 66.7 | 1.615 | 0.374 |
| Trans-female | 0 | 1 | 1 | 0.0 | 0 | 0.588 |
| Other | 9 | 12 | 21 | 42.9 | 1.038 | 0.888 |
| Race | ||||||
| Non-Hispanic White | 130 | 130 | 260 | 50.0 | ref | |
| Hispanic White | 18 | 21 | 39 | 46.2 | 0.923 | 0.654 |
| Black | 97 | 228 | 325 | 29.8 | 0.597 | <0.001 |
| Asian, native Hawaiian, other Pacific Islander | 18 | 19 | 37 | 48.6 | 0.973 | 0.878 |
| American Indian/Alaska Native | 3 | 8 | 11 | 27.3 | 0.545 | 0.121 |
| Other | 10 | 16 | 26 | 38.5 | 0.769 | 0.262 |
| Insurance | ||||||
| Employer insurance | 135 | 138 | 273 | 49.5 | ref | |
| Uninsured | 29 | 66 | 95 | 30.5 | 0.617 | 0.001 |
| Medicare | 7 | 18 | 25 | 28.0 | 0.566 | 0.040 |
| Medicaid | 36 | 90 | 126 | 28.6 | 0.578 | <0.001 |
| Family member | 37 | 64 | 101 | 36.6 | 0.741 | 0.027 |
| DC Health link | 19 | 27 | 46 | 41.3 | 0.835 | 0.306 |
| Meeting partners | ||||||
| Social situations | 93 | 132 | 225 | 41.3 | 1.079 | 0.487 |
| Clubs/bars | 55 | 55 | 110 | 50.0 | 1.532 | 0.014 |
| Social media | 47 | 73 | 120 | 39.2 | 0.987 | 0.936 |
| Apps | 153 | 175 | 328 | 46.6 | 1.340 | 0.000 |
| Cruising | 13 | 22 | 35 | 37.1 | 0.905 | 0.770 |
| School/neighborhood | 43 | 71 | 114 | 37.7 | 0.925 | 0.671 |
| Last STI test | ||||||
| Never | 25 | 36 | 61 | 41.0 | ref | |
| <1 month | 5 | 9 | 14 | 35.7 | 0.871 | 0.481 |
| 1−3 months | 38 | 48 | 86 | 44.2 | 1.078 | 0.699 |
| 4−6 months | 47 | 64 | 111 | 42.3 | 1.033 | 0.863 |
| 7−12 months | 61 | 86 | 147 | 41.5 | 1.013 | 0.945 |
| >12 months | 87 | 160 | 247 | 35.2 | 0.859 | 0.402 |
| Total partners, mean (95% CI) | 4.43 (3.875, 4.977) | 3.37 (3.325, 4.14) | 0.046 | |||
| Sexual partnering | ||||||
| MSM | 89 | 106 | 195 | 45.6 | 1.287 | 0.037 |
| MSMW | 6 | 3 | 9 | 66.7 | 3.065 | 0.093 |
| MSW | 39 | 75 | 114 | 34.2 | 0.797 | 0.205 |
| WSM | 111 | 185 | 296 | 37.5 | 0.919 | 0.348 |
| WSW | 8 | 10 | 18 | 44.4 | 1.226 | 0.663 |
| WSWM | 7 | 17 | 24 | 29.2 | 0.631 | 0.292 |
| STI history | ||||||
| CT | 66 | 79 | 145 | 45.5 | 1.280 | 0.093 |
| GC | 47 | 42 | 89 | 52.8 | 1.715 | 0.006 |
| HIV | 1 | 9 | 10 | 10.0 | 0.170 | 0.055 |
| Syphilis | 14 | 17 | 31 | 45.2 | 1.262 | 0.508 |
| No history of STI | 165 | 292 | 457 | 36.1 | 0.866 | 0.008 |
| Why choosing mail-in STI testing | ||||||
| Site difficult to reach | 33 | 52 | 85 | 38.8 | 0.972 | 0.893 |
| Past experiences at nearby test site(s) | 8 | 18 | 26 | 30.8 | 0.681 | 0.353 |
| Don't know where to go | 23 | 29 | 52 | 44.2 | 1.215 | 0.466 |
| On PrEP | 8 | 7 | 15 | 53.3 | 1.751 | 0.267 |
| Don't want people to know | 31 | 69 | 100 | 31.0 | 0.688 | 0.060 |
| Convenience | 171 | 246 | 417 | 41.0 | 1.065 | 0.300 |
| COVID-19 | 173 | 243 | 416 | 41.6 | 1.091 | 0.153 |
| Mailing address ZIP and CT/GC morbidity | ||||||
| Address in 3 highest STI morbidity ZIP | 66 | 139 | 205 | 32.2 | 0.723 | 0.009 |
| Address in 5 highest STI morbidity ZIP | 108 | 207 | 315 | 34.3 | 0.795 | 0.007 |
| Address in 10 highest STI morbidity ZIP | 192 | 316 | 508 | 37.8 | 0.925 | 0.078 |
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
| HIV | STI | Total | ||||
|---|---|---|---|---|---|---|
| Survey questions | n | % | n | % | n | % |
| When were test kit(s) delivered? | ||||||
| 3 business days | 89 | 28.4 | 29 | 33.0 | 118 | 29.4 |
| Within a week | 160 | 51.1 | 53 | 60.2 | 213 | 53.1 |
| Within 1−2weeks | 43 | 13.7 | 4 | 4.5 | 47 | 11.7 |
| >2 weeks | 21 | 6.7 | 2 | 2.3 | 23 | 5.7 |
| How long until using test? | ||||||
| Within a day | 194 | 59.5 | 34 | 38.6 | 228 | 55.1 |
| Within a week | 86 | 26.4 | 44 | 50.0 | 130 | 31.4 |
| Within a month | 32 | 9.8 | 10 | 11.4 | 42 | 10.1 |
| Not taken | 14 | 4.3 | 0 | 0.0 | 14 | 3.4 |
| Results | ||||||
| Negative | 309 | 99.0 | 81 | 92.1 | — | — |
| Positive | 0 | 0.0 | 7 | 8.0 | — | — |
| Can't tell | 3 | 1.0 | — | — | — | — |
| When planning to repeat test? | ||||||
| <1 month | 8 | 2.6 | 1 | 1.1 | 9 | 2.2 |
| 1−3 months | 115 | 36.7 | 42 | 47.7 | 157 | 39.2 |
| 4−6 months | 110 | 35.1 | 19 | 21.6 | 129 | 32.2 |
| 7−12 months | 35 | 11.2 | 11 | 12.5 | 46 | 11.5 |
| >2 months | 14 | 4.5 | 5 | 5.7 | 19 | 4.7 |
| I don't know | 28 | 8.9 | 10 | 11.4 | 38 | 9.5 |
| I won't get another test | 3 | 1.0 | 0 | 0.0 | 3 | 0.7 |
| Would you recommend this test kit? | ||||||
| Yes | 321 | 98.5 | 86 | 97.7 | 407 | 98.3 |
| No | 5 | 1.5 | 2 | 2.3 | 7 | 1.7 |
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.
21
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.1
DC.gov., DC Health
HAHSTA annual epidemiology & surveillance report 2020.
HAHSTA annual epidemiology & surveillance report 2020.
DC.gov., DC Health,
Washington, DCPublished August 20, 2020
https://dchealth.dc.gov/node/1492101
Date accessed: January 11, 2021
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.
REFERENCES
- HAHSTA annual epidemiology & surveillance report 2020.DC.gov., DC Health, Washington, DCPublished August 20, 2020https://dchealth.dc.gov/node/1492101Date accessed: January 11, 2021
- Treatment of sexually transmitted infections for HIV prevention: end of the road or new beginning?.AIDS. 2010; 24: S15-S26https://doi.org/10.1097/01.aids.0000390704.35642.47
- Self-testing for HIV and its impact on public health.Sex Transm Dis. 2014; 41: 10-12https://doi.org/10.1097/OLQ.0000000000000076
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.
- Examining the effects of HIV self-testing compared to standard HIV testing services: a systematic review and meta-analysis.J Int AIDS Soc. 2017; 20: 21594https://doi.org/10.7448/IAS.20.1.21594
- Bringing HIV self-testing to scale in the United States: a review of challenges, potential solutions, and future opportunities.J Clin Microbiol. 2019; 57e00257–19https://doi.org/10.1128/JCM.00257-19
- Relative accuracy of serum, whole blood, and oral fluid HIV tests among Seattle men who have sex with men.J Clin Virol. 2013; 58: e119-e122https://doi.org/10.1016/j.jcv.2013.09.018
- Community-based chlamydia and gonorrhea screening through the United States mail, San Francisco.Sex Transm Dis. 2002; 29: 294-297https://doi.org/10.1097/00007435-200205000-00008
- 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].Sex Transm Dis. 2006; 33: 451-457https://doi.org/10.1097/01.olq.0000200497.14326.fb
- Use of home-obtained vaginal swabs to facilitate rescreening for Chlamydia trachomatis infections: two randomized controlled trials.Obstet Gynecol. 2011; 118: 231-239https://doi.org/10.1097/AOG.0b013e3182246a83
- Home compared with clinic-based screening for sexually transmitted infections: a randomized controlled trial.Obstet Gynecol. 2010; 116: 1311-1318https://doi.org/10.1097/AOG.0b013e3181fae60d
- Home screening for sexually transmitted diseases in high-risk young women: randomised controlled trial.Sex Transm Infect. 2007; 83: 286-291https://doi.org/10.1136/sti.2006.023762
- Bacterial sexually transmitted disease screening outside the clinic–implications for the modern sexually transmitted disease program.Sex Transm Dis. 2016; 43: S42-S52https://doi.org/10.1097/OLQ.0000000000000343
- Can e-technology through the Internet be used as a new tool to address the Chlamydia trachomatis epidemic by home sampling and vaginal swabs?.Sex Transm Dis. 2009; 36: 577-580https://doi.org/10.1097/OLQ.0b013e3181a7482f
- The potential impact and availability of sexual health services during the COVID-19 pandemic.Sex Transm Dis. 2020; 47: 434-436https://doi.org/10.1097/OLQ.0000000000001198
- Characterizing the impact of COVID-19 on men who have sex with men across the United States in April, 2020.AIDS Behav. 2020; 24: 2024-2032https://doi.org/10.1007/s10461-020-02894-2
- NETSS Internal Surveillance Data, Internal Communication.2021
- Sex in the time of COVID-19: results of an online survey of gay, bisexual and other men who have sex with men's experience of sex and HIV prevention during the U.S. COVID-19 Epidemic.AIDS Behav. 2021; 25: 40-48https://doi.org/10.1007/s10461-020-03024-8
- 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.Drug Alcohol Depend. 2020; 216108260https://doi.org/10.1016/j.drugalcdep.2020.108260
- COVID-19 pandemic, pre-exposure prophylaxis (PrEP) care, and HIV/STI testing among patients receiving care in three HIV epidemic priority states.AIDS Behav. 2021; 25: 1361-1365https://doi.org/10.1007/s10461-021-03195-y
- Estimating the population sizes of men who have sex with men in U.S. states and counties using data from the American Community Survey.JMIR Public Health Surveill. 2016; 2: e14https://doi.org/10.2196/publichealth.5365
Article info
Footnotes
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).
Identification
Copyright
© 2021 American Journal of Preventive Medicine. Published by Elsevier Inc.
User license
Creative Commons Attribution – NonCommercial – NoDerivs (CC BY-NC-ND 4.0) | How you can reuse 
Elsevier's open access license policy
Creative Commons Attribution – NonCommercial – NoDerivs (CC BY-NC-ND 4.0)
Permitted
For non-commercial purposes:
- Read, print & download
- Redistribute or republish the final article
- Text & data mine
- Translate the article (private use only, not for distribution)
- Reuse portions or extracts from the article in other works
Not Permitted
- Sell or re-use for commercial purposes
- Distribute translations or adaptations of the article
Elsevier's open access license policy
