Improving access to sexual health tests, by making them available without a pretest consultation, and without the patient having to travel to a fixed location, can improve access, and therefore help to reduce the number of patients who are unaware that they are infected. Subsequently, this can reduce transmission and reduce overall infection rates. 

However, without the guidance of a clinician, additional measures need to be taken to ensure the test, and results, are delivered in an appropriate and safe manner. Sexual health tests have some additional considerations, beyond routine, non-sexual health tests. 

At Hurdle we aim for the highest of clinical, scientific and technical standards. Here I we discuss the things to consider before launching any online sexual health testing service.

The patient

Online self-request sexual health tests are not suitable for everyone. Where there are difficulties in communication or uncertainty about consent, face to face services are preferred. 

Patients aged below 18 years of age require a risk assessment for Child Sexual Exploitation (CSE) such as ‘Spotting the Signs’; this cannot be done via an online form, and so it is would recommend these patients are seen face to face. 

Pretest counselling

In face to face consultations, the clinician normally has the full patient record available, and they can read verbal and non-verbal cues of the patient, and so direct their questioning and advice appropriately. Where an online form and predefined patient pathway replaces the clinician’s judgement, the information provided to the patient needs to be more extensive. 

Patients must be given adequate information about the test and the service, before they take the test. This should include the following as a minimum.

Accuracy

Levels of accuracy must be listed. Bearing in mind that the average reading age in the UK is between 9 and 11 years old, detailing sensitivity and specificity is less useful than an overall average. If you would like to ensure you communicate the precise details ensure you give definitions for any technical terms 

What is being tested exactly

For diseases like hepatitis B, you may be testing for antigen (infection) or antibodies (immune response) and for HPV there are different strains. Patients may have specific use cases, or be comparing different tests online, and so should have that information available to them. 

Testing windows

Patients must be informed of the timescales for an accurate result; in other words, how long after exposure will the test be accurate. If you are providing this service on behalf of a laboratory, ensure you request the assay information sheet from the manufacturer. Further information regarding accuracy can be found online, but ensure this is from high quality evidence such as systematic reviews, and relevant to the exact assay that will be used in your test.

Timescales

Patients need to be informed how long it will take for the test result to be returned. Those who are travelling, or worried, may want to have a test taken, and a result provided in timesales that you cannot meet in an online service. 

Results delivery

Ensure patients know how they will receive their results beforehand. Some online services offer a doctor consultation and/or a prescription with the results, others don’t; give patients the opportunity to decide to use the service that is appropriate for them. 

Symptomatic?

Where a patient has symptoms, a full sexual health assessment is usually required, and different forms of tests are preferred. Ensure the patient knows the limitations of the test they are going to take, so that their treatment and appropriate tests are not delayed. 

Abstinence

If a patient thinks that they may have an infection, it is important that they are informed to abstain from all sexual contact immediately, and until they have a negative test result. The inherent delay in postal testing means this advice is essential to prevent the spread of infections.

Medication 

Results may be affected by the use of antibiotics, PREP, PEP and other anti-retrovirals. Patients taking these will need to be appropriately advised, any may be more suitable for a review by a specialist in sexual health.

The importance of screening

National screening programmes are the gold standard for testing, and so any test outside of the screening programme should be supplementary; ie it doesn’t replace the need for screening. 

Implications of a positive result

If the online testing service is publicly funded in the UK, there are additional requirements to inform the UK Health Security Agency via GUMCADv2 and CTAD Surveillance Systems; however services which are entirely private are not bound by the same rules. Ensure patients know what will happen with their data. (Note it is also important to clearly define with the testing laboratory who has responsibility for notification of results to government agencies.)

Positive results may require repeat testing on the same sample, confirmatory testing with a subsequent sample, or tests for other conditions; ensure that the patient is aware of this before taking the test.   

Test kits

Packaging

Test kits may be being delivered to offices, family homes or shared accommodation. Ensure that the outer packaging doesn’t list the type of test, or the service from which it is being sent. Kits must be small enough to fit into most domestic post boxes, otherwise there will be a delay in them reaching the patient. 

Certification

Ensure that all test kits have received appropriate MHRA/CE marking; which will ensure the quality of the kit and the accompanying instructions. 

Postage

Any delay in posting can result in the spread of disease, and patient anxiety, so kits should ideally be posted within 1 working day of the order being placed, with a postage-paid envelope for returning samples. 

Results delivery

How results are delivered is incredibly important, particularly if a clinician appointment will not be available. It is important to pre-empt any questions patients may have so that they feel reassured and fully informed when receiving results and the accompanying copy. 

Positive test results

Abstinence

The most important advice that accompanies a positive result is the need for a patient to abstain from all forms of sexual contact; to prevent the spread of infections.

Patients should be advised that this period of abstinence does not end until a test has been undertaken to prove successful treatment has been completed. 

Partner notification

Patients should be encouraged to inform current and past partners of any infections. Ideally an anonymous notification system will allow patients with positive results to enter the contact details of their partners, triggering an immediate invitation for testing; without naming the infected patient. 

Need to see clinician

Where one infection has been found, other infections need to be ruled out, so further testing should be advised for anyone with a positive result.

Treatment

Where a clinician appointment is available, this should be offered to the patient as soon as possible. Where the service does not include a clinician review, the patient should be appropriately signposted to local sexual health clinics. A simple link to the NHS service finder enables patients to search by postcode: https://www.nhs.uk/nhs-services/sexual-health-services/ 

If confirmatory test is required

Where confirmatory tests are required, patients should be informed as soon as possible (see more details below)

Negative and inconclusive test results

Validity

With a negative result it is important to remind patients of the accuracy of the test, and any circumstances which may have made the result invalid; such as use of antibiotics or taking the test too soon after exposure. 

If symptomatic

Some tests have a sensitivity and specificity based on asymptomatic patients; it is important to remind patients of this when providing a negative result.

Other infections

A patient who tests negative for one infection, may be suffering from another infection. Reminding patients what they have and haven’t been tested for is important, to educate them of the need to undertake further testing.  

Inconclusive results

Inconclusive results may provide false reassurance, so the wording of an inconclusive result is important, to motivate patients to seek further testing. 

Video consultations

Video consultations provide patients with the opportunity to ask questions and benefit from the reassurance of speaking to a healthcare professional.

Positive results

Ideally all positive results would be delivered by a clinician, but in the absence of this, basic advice and signposting is the minimum that should be offered to patients.

Optional links

Linking to a telehealth service may be a simple solution for private providers, where the patients can be offered a video consultation if they wish to discuss their results. 

HIV confirmatory results

Where a patient has a positive HIV confirmatory test, the results must be delivered by a clinician. Any service that doesn’t offer video consultation should not be offering confirmatory HIV tests. 

Biopsychosocial aspects

Any consultation where a positive result is discussed should attend to the physical, social and emotional needs of the patient. This should include next steps, further support and partner notification.  

Follow up tests

Patients, and providers, are often unaware that the initial test may not be definitive, or that further testing may be required. Patient, lab and technical flows should be built to allow retesting in the following scenarios:

• Inconclusive results will require retesting with a new sample being sent to the patient.
• Gonorrhoea confirmatory tests may be required using the same sample, but with a different assay or machine in the lab.
• HIV will require further sampling and testing for confirmation of the virus
• Following treatment, some infections will require a further test to ensure the infection has cleared Any positive test will require full sexual health screen, for all common infections
  • Although this is most commonly carried out in a sexual health clinic

 

Special cases

There are some other things to consider before launching an online sexual health testing service, that may not be obvious initially. 

Guidance for transgender patients

Patients who are transgender may not be suitable for some services; however general advice is to advise the patient to test based on their genitalia, as physically that is where infection occurs. If they have both male and female genitalia, then they will need to test both. 

This is an evolving practice, so some providers may struggle, but it is important to ensure equity of access for all groups. This may include kits that include tests for patients with male and female genitalia.

Languages

All providers, particularly those providing testing for the public sector, should aim to make all test copy, including test kits, available in multiple languages. 

Risk assessment 

Risk assessments without a live consultation are difficult, but patients must be advised to seek help if they have had sexual intercourse without consent. 

Advice on timing with menstruation

Some tests, urine and swabs, may require the patient to take the sample when not menstruating; ensure that this is included in the pretest advice. 

Safety of using swabs if pregnant

Pregnant women may have concerns about using swabs when pregnant, ensure that the swab manufacturer’s guidance on this is clearly communicated before the patient takes the test.

Certified tests

Where tests, such as HIV and Hep B, are being used for occupational health purposes, they will need an appropriate identity check, so may not be suitable for online testing services. However, increasingly, suppliers are undertaking observed testing, where the ID of the patient is checked and they are then observed undertaking the test. Naturally this cannot be done for urine or swabs of genitalia. 

Quality control

Ensuring the quality and security of the service has additional importance in sexual health testing, due to the sensitive nature of the conditions being tested for.

Auditing

Auditing of tests, particularly those which the lab was unable to complete, or where the result was inconclusive, is important and enables constant refinement of each part of the testing process, from delivery of kits to kit instructions and lab processes.

Feedback

Feedback, both formal and informal, from users should be treated sensitively, acknowledging the validity of the user’s experience and point of view, which may be different to what is obvious to the provider of the service. 

Qualifications

Ensure any organisations who have access to patient data, or are involved in the testing service or delivery of results are appropriately accredited, including UKAS, GDPR and Cyber Essentials.  

Further reading

BASHH Standards for Online and Remote Providers of Sexual and Reproductive Health Services https://www.bashh.org/_userfiles/pages/files/bashhfrshjointstandardsforonlineandremoteproviders2019x.pdf 

 

Guidance to assist staff involved with the collection, recording, analysis or interpretation of data from CTAD and GUMCADv2.

https://www.gov.uk/government/publications/chlamydia-guidance-on-reporting-in-ctad-and-gumcadv2 

 

GMC Good Medical Practice

https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/good-medical-practice

 

Data Security and Protection Toolkit- NHS Digital

https://www.dsptoolkit.nhs.uk