Home sampling for STI tests in Greenwich: evaluation highlights David Pinson Public Health & Well-Being Royal Borough of Greenwich
Presentation Background About the evaluation Profile of users User reactions Summary Page 2
Background Percentage of 16-44 year-olds in the UK attending a sexual health clinic in the past year 25% 20% 15% 10% 1999-2001 (Natsal 2) 2010-2012 (Natsal 3) 5% 0% Men Women Sonnenberg P, Clifton S, Beddows S, Field N, Soldan K, Tanton C, et al. Prevalence, risk factors, and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). The Lancet 2013; 382: 1795 806. Page 3
Background Emergence of home-sampled STI tests Page 4
Background Cost per screen: STI testing based on home sampling is cheaper 180 160 140 31% 120 100 80 60 48% SH office Diagnostic tests Unreturned kits Kit Tariff 40 20 0 GUM screen Screen based on home sampling (non MSM) Screen based on home sampling (MSM) GUM testing cost from 2015/16 national GUM tariff for Outpatient First Appointment. Costs for screens based on home samples are from TDL. Cost of lost kits assumes 50% return rate (i.e. 2 kits required per screen). Kits and tests are more expensive for MSMs because they include swabs to test for rectal and pharyngeal chlamydia and gonorrhoea. SH office = sexual health office. This is the cost of providing a telephone service for people who need information, advice or referral. Metro s estimate of the total cost is 16,400 for the first year, which has been spread over an assumed 1,000 screens (= 16.40/screen). Page 5
About the evaluation Aims and methods Aims Potential to provide a cheaper and more useracceptable method Recommendations on scaleup Methods Literature review Analysis of service data Qualitative interviews Survey of kit users and sexual health clinic users Cost/benefit modelling Page 6
About the evaluation User groups High 1. Migration 3. Extending screening in a risk group Risk Low 2. Migration 4. New demand from worried well Yes Would have tested at a clinic No Page 7
Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Profile of users Kit requests and returns 120 100 80 60 40 20 0 Requests Returns Request numbers provided by Ministry (GSH website host). Return numbers provided by Metro. Page 8
Profile of users Demographics of sexual health service users: HSK users are typically from lower-risk groups than clinic users 100% 90% 80% 70% 60% Mixed Asian Black Other white Other Mixed Asian Black Mixed Asian Black Other white 65+ 45-64 45-64 35-44 35-44 25-34 Female Female Female 50% 40% Other white 35-44 25-34 MSM MSM 30% 20% 10% 0% British Adult residents British GUM clinic visits British HSK returns 25-34 20-24 20-24 20-24 16-19 16-19 16-19 Adult residents GUM clinic visits HSK returns Male Adult residents Male GUM clinic visits MSM Male HSK returns Adult residents from Census 2011, Nomis. GUM clinic visits from GUMCADv2 surveillance, Public Health England, 1/8/13-30/9/14. HSK data provided by Metro, 1/8/13 1/10/14. Page 9
Profile of users Prevalence of chlamydia infections in urine, with 95% CIs: HSK users have less than half the rate of infections of clinic users 14% 12% 10% 8% 6% 11.0% 4% 8.3% 7.7% 2% 0% 3.5% Greenwich HSKs (median age 25) 5.0% Greenwich HSKs (age 15-24) Greenwich NCSP, 2013 (age 15-24) Greenwich residents at any GUM (estimated mean age 31) Greenwich residents at any GUM (age 15-24) 1.1% 1.5% UK population: men (age 16-44) UK population: women (age 16-44) HSK data provided by Metro, 1/8/13 5/3/15. GUM data from GUMCADv2 surveillance, Public Health England, 30/09/2013 30/09/2014. UK population data from Natsal3: Sonnenberg P, Clifton S, Beddows S, Field N, Soldan K, Tanton C, et al. Prevalence, risk factors, and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). The Lancet 2013; 382: 1795 806. NCSP data from Public Health England. Tables 1-4: Chlamydia testing data for 15-24 year olds in England, January to December 2013. 2014. (http://www.chlamydiascreening.nhs.uk/ps/resources/datatables/ctad%20data%20tables%202013%20annual%20data%20%20for%20publication_final130614.pdf) Page 10
Profile of users When were you last tested? Never Within the last year A long time ago Within the last few years Data provided by Metro, 1/8/13 1/10/14. Page 11
User reactions (1) Users have been highly satisfied 95% would use the kit again. Of users who have also tested in a clinic, 73% felt the kit was better and only 9% felt it was worse. Many of the free-text comments are positive and show that users feel the kit is easy, simple, quick and convenient. Qualitative interviews suggest that convenience is the main attraction of the kit. Survey of kit users, March 2015 (n=57). Qualitative interviews with kit users (n=10) conducted March-April 2015. Page 12
User reactions (2) Many users find the self-blood sample difficult 47% rated the blood sample quite or very difficult (vs. 5% for urine and 0% for swabs). Qualitative feedback suggests that many (but not all) users found it difficult to draw enough blood. 19% of blood tests could not be performed because there was not enough blood. 30% of users received at least one insufficient sample result. Improvements have been made to the equipment and guidance. Survey of kit users, March 2015 (n=57). Qualitative interviews with kit users (n=10) conducted March-April 2015. Test result data provided by Metro (August 2013 February 2015). Page 13
Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 Blood sampling Proportion of users receiving at least one insufficient sample result from their blood tests: big improvement 50% Summer 2014: Clearer instructions Winter 2014: New box layout 40% Jan 2015: New lancet 30% 20% 10% 0% Data provided by Metro Page 14
User reactions (3) Users appear to be health-conscious, generally low risk, and regular users of sexual health services 68% of users have tested within the past few years. Only 11% have not previously tested. Typical comments from the qualitative interviews: I m quite cautious. Even if nothing s happened I like to get tested now and again. I was almost sure I didn t have anything. It was for peace of mind. I use the kit once per month. If I could I would test every two weeks. I m over-safe. Testing history from website order form (data provided by Metro). Qualitative interviews with users (n=10) conducting March-April 2015. Page 15
User reactions (4) Some users may distrust the service A minority of existing users did not trust the kit to provide a full sexual health screen: To get everything done, you have to go to the local sexual health clinic. I did go to a clinic for everything afterwards. I wanted to get everything tested. I got tested at the clinic as well. It s much more through than the home kit. They check everywhere, blood tests, swabs. I didn t think the home testing kit would give an accurate reading I m doing it myself, and as I m not a doctor or nurse, it s not going to be accurate. Qualitative interviews with users (n=10) conducting March-April 2015. Page 16
Summary Key evaluation findings Home-sampling is cheaper per test People like it for the convenience (with privacy as a secondary driver) Blood sampling is hard but the barriers are surmountable Users have been risk with low infection prevalence A significant minority of clinic users would be willing to switch to home sampling (we estimate 25%) Page 17
Summary Priorities in Greenwich Build migration into clinical consultation in GUM clinic / promote kit at clinics Emphasise validity and comprehensiveness of the tests Review potential for health promotion Page 18
Contact david.pinson@royalgreenwich.gov.uk Page 19