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Home tests for sexually transmitted infections: When to order one, when to see a doctor

Rising infections has led to expansion of sexual home testing kits, but are they reliable?

The availability of free home test kits for sexually transmitted infections (STIs) has been expanded by the Health Service Executive (HSE) from three to 14 counties since the beginning of November.

Not that the HSE is shouting about it, having been overwhelmed by demand at the start of the pilot scheme last January.

The initiative is a response to the increasing rates of STIs and a corresponding rise in demand for testing experienced in Ireland in recent years – at least, up to the start of the pandemic. But, with echoes of the current controversy about home antigen testing for Covid-19, it is stressed that home testing for STIs "is for individuals who do not have symptoms of an STI". If you do have symptoms, a clinic visit is advised (more information on sexualwellbeing.ie).

Some health professionals fear that, as with antigen testing, there will be incidents of “false negatives” and, in the absence of any clinical examination, those individuals will unwittingly spread STIs to others in the belief that they are in the clear. However, unlike antigen testing, you don’t get the results there and then in your home, samples have to be sent to a laboratory for processing.

When the HSE first offered home STI testing to people living in Dublin, Cork and Kerry on January 5th last, 4,921 test kits were ordered within the first 24 hours, far exceeding expectations. The online service had to be suspended at that point, to allow the orders already received to be dealt with and to ensure the public STI clinics involved could cope with the people who required additional testing, treatment or support.

It wasn’t until March that ordering of the test kits resumed and a limit on the number available each day was introduced, to ensure clinics had sufficient capacity to see individuals who needed to have their results followed up. For the remainder of the pilot period, 200 test kits were available each day, seven days a week.

The service can now send out up to 220 kits a day, with availability varying across the 14 counties. The scheme now covers Cavan, Cork, Dublin, Galway, Kerry, Kildare, Laois, Louth, Mayo, Meath, Monaghan, Offaly, Roscommon and Wicklow. "The cap is in place to safeguard against the service going viral and thousands of orders being received overnight as happened in January when the service was launched," an HSE spokeswoman explains in response to queries from The Irish Times. "Only a few areas, such as Dublin, regularly reach their daily ordering cap."

How does it work?

If you're aged 17 or over and live in one of the 14 designated counties, you can go online to sh24.ie to order a home test kit that comes with full instructions. The type of test you receive is based on the risk assessment you complete when ordering a test. You can be tested for HIV, syphilis, chlamydia and gonorrhoea, with hepatitis B and C tests offered as required.

The nature of the samples you need to return for testing, ie blood, urine, oral, anal or vaginal swabs, will depend on gender and sexual preference.

Results should be available within 72 hours of your samples reaching the laboratory. In some circumstances, people are contacted via SMS text message and in other cases by telephone. Those with results necessitating further care are directed to free, HSE-funded public STI services for repeat testing and/or treatment as required.

Some 32,948 kits were dispatched between the start of the pilot in January and up to the end of October. Over the first five months, 67 per cent of the kits were returned and results from 8 per cent of those required follow-up care. “The online STI testing service is reaching individuals who may not otherwise attend a sexual health service or access STI testing,” says the HSE. During the pilot, 57 per cent of service users said they had never accessed a sexual health service before.

STI testing is recommended by the HSE if:

  • You have any symptoms which suggest an STI (but a clinic visit is advised in that case)
  • Your partner has an STI
  • You have a new sexual partner
  • You have more than one sexual partner

The Union of Students in Ireland's vice-president for welfare, Somhairle Brennan, welcomes the recent expansion of the scheme and says a full, national rollout "would be a huge step forward for Ireland societally and how we talk about sexual health".

Figures from the Health Protection Surveillance Centre (HPSC) for notifications of STIs in 2019 and 2020 show that those aged 20-24 are most likely to be affected by the three most common infections: chlamydia (the rate among men and women being roughly equal); gonorrhoea (predominantly occurs in men); and herpes simplex (genital), which mostly affects women.

“The costs of medical supplies and treatment are extremely expensive and can have a huge toll on a student, particularly their mental health, so having the opportunity to access those services without those additional costs are obviously going to be massively welcome,” says Brennan.

He believes students have become much more proactive about their sexual health in recent years and that “we’re in a time of destigmatisation of discussion around sexual health”. There is a normalisation of getting yourself checked regularly for STIs, “just as another part of your life”. With this practice being “massively common” on the queer scene, he personally believes the LGBT+ movement has made a huge contribution to better sexual health in this regard.

You will find most of the cases, but you won't find all the cases

Dr Derek Freedman, a consultant genito-urinary physician who has specialised in STIs and sexual health since the 1980s, has mixed views on the HSE rollout of home test kits. "They have a place, but do not replace a consultation, and they are being used as a sticking plaster for inadequate resources," he says. Switching to greater use of this mass-screening method for STIs means a potential reduction in sensitivity and specificity. "You will find most of the cases, but you won't find all the cases."

If a person is anxious about a possible infection, he believes a full examination, with a complete set of sensitive and accurate diagnostic tests is what is required. “A home testing kit will not pick up everything. Some conditions, like genital warts, need an examination, and so often people worry about little things that are completely normal. You can only reassure them with an examination.”

People should also be aware that if they have ever had syphilis, their blood will always test positive for it even if the infection has cleared

Quite apart from the HSE’s free online service, there are global businesses selling self-test kits for STIs. One problem he has with some of these commercialised ones are “inappropriate tests”, offering tests for, say, ureaplasma – naturally occurring bacteria in urinary and reproductive tracts of both men and women – that are not considered pathogens.

"We don't test for ureaplasma because it is normally present," says Freedman, who runs a private clinic in Ranelagh, Dublin. He also warns against any kits that purport to test for herpes and syphilis through urine samples, as these can be detected only in direct samples from a lesion, or in blood samples. People should also be aware that if they have ever had syphilis, their blood will always test positive for it even if the infection has cleared.

“We have an epidemic of syphilis and that is something that shouldn’t be here at all,” he says. “It is so easily treated and cured. It is getting people to attend for testing that is the problem.”

The HPSC recorded 787 cases of early infectious syphilis in 2019, which was 63 per cent up from the previous year; 611 cases were then notified during the pandemic-hit 2020. It’s impossible to know if last year’s drop in the number of notifications is due more to changed behaviour during lockdown or to reduced sexual health and GP services, with fewer opportunities for testing.

With people being much more open about sexual health, there isn’t the same reluctance to attend a clinic for examination as there was years ago, Freedman suggests. When people come in for genital examinations, “we can pick up other conditions, including some cancers” – and you can’t pick those up through posted tests. Consultations also give a chance for counselling, “not only about safe sex, and reducing sexual dysfunction, but also pointing them to quality sex, which is something we don’t always appreciate”.

Initiatives like this, Freedman adds, are “quick fixes, politically attractive but, in reality, I’d be wary”. The bottom line is that the services need adequate resources to do a proper job.

Despite increasing openness in Ireland about sexual health, the privacy that home testing offers is obviously part of the appeal and why businesses have been able to sell such a service. For example, when the Irish home test company Let’sGetChecked was launched in 2015, it sold only sexual health tests, although it has expanded its range considerably since.

However, its “Standard 6” test kit covering six STIs remains its most popular product overall, according to a company spokeswoman. It costs €119 online, requires both blood and urine samples to be sent back for testing, and free prescriptions are provided, if necessary, for chlamydia and trichomoniasis.

A survey of sexual health services in Ireland in 2018 had highlighted the inequity in access to public STI services, which were already struggling to cater for the increasing demand

The majority of Let’sGetChecked customers are based in the US and its online, direct-to-consumer sales over its entire range are split roughly 50/50 male and female, the spokeswoman adds.

The HSE Sexual Health & Crisis Pregnancy Programme (SHCPP) secured Sláintecare funding to pilot online STI testing, in conjunction with the public STI clinics. Not only were there rising rates of STIs but a survey of sexual health services in Ireland in 2018 had highlighted the inequity in access to public STI services, which were already struggling to cater for the increasing demand.

“The online STI testing model has shown to be effective in other countries,” says the HSE spokeswoman. “It can improve the sexual health of populations through rapid diagnosis and treatment of infections. It can improve productivity by moving patients who are asymptomatic out of the acute clinical setting to an online setting, allowing for more appropriate use of clinic time, such as the management of the more complex cases.”

Testing those who are asymptomatic through an online platform can, she adds, be more cost effective than in a clinical setting.

The HSE’s contract for the pilot service was with the online provider SH:24, which is based in the UK and delivers sexual health services in partnership with the NHS there. The HSE confirms it is now embarking on the tender process for an online provider to deliver this service on a national basis.

Chlamydia, Ireland’s most common STI, by numbers

  • 9,173 cases notified in 2019 (192.4 per 100,000 population), up 16 per cent on 2018 figures
  • 6,937 cases notified in 2020, with the 24 per cent drop attributed to the impact of the pandemic
  • 147.2 cases per 100,000 was the rate among females in 2020, slightly higher than the male rate (142.9/100,000)
  • 50 per cent of cases in 2020 were among people aged 15-24 years

Source: Health Protection Surveillance Centre

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